Periods, or menstruation, is one of India’s favourite taboos. The biological process can be discussed in an open courtroom to decide the fate of women’s rights but the reality is that women across India continue to remain apprehensive about opening up about their own bodies to their gynaecologists. And in a country that seldom talks about women’s sexual health in an informed manner, a significant number of women in the reproductive age have Polycystic Ovary Syndrome (PCOS).
While weight gain and periods are more often discussed, there are also fears of being infertile, or the effect on a woman’s sex drive. For solutions, they turn to the closest thing they can find – Google; or worse, social media. But Dr Google doesn’t have all the answers. Does PCOS affect a woman’s sex life? Nope. Does it leave a woman incapable of becoming pregnant? Also untrue.
Polycystic ovaries
Around 12-15% of the women in India have Polycystic Ovary Syndrome (PCOS), but information remains limited. One of the foremost indicators for women with PCOS is that they have irregular cycles — cycles which are less than 21 days or over 35 days.
When a woman or a young girl realises she has PCOS, the word ‘polycystic’ triggers off alarms. However, PCOS is a hormonal disorder, and a manageable one.
During a woman’s period, an egg is released by an ovary, cuing the start of her menstruation cycle. However, polycystic ovaries occurs when the egg is not released by the ovaries. To detect if a woman has PCOS, an ultrasound test is usually conducted. Women with PCOS tend to present with slightly larger ovaries along with follicles. The follicles, which are essentially nurseries for the eggs, release an egg every 14 days. Fourteen days later, a woman has her period. If that egg is not being released for some reason, these follicles resemble a pearl necklace, which are basically unreleased eggs. When this happens, the period either gets delayed, or it doesn't occur at all.
A woman’s body has both oestrogen, the female sex hormone, and the testosterone, the male sex hormone. Testosterone is usually present in a smaller amount. Essentially, PCOS is a hormone disorder where women produce a higher-than-usual amount of testosterone.
So, what symptons should you be looking for?
The clearest indicator for women with PCOS is that they may have irregular cycles. However, while it may be the most obvious indicator, it’s not the only one.
“When we say PCOS, it is a broad spectrum. It can start with just slightly regular cycles or it can be full blown PCOS, where there are no periods unless she takes tablets; a lot of unwanted hair growth on the face like a male pattern, and a lot of pimples and a lot of outbreaks of acne which are really bad, and, of course, weight gain issues,” says Dr Aruna Muralidhar, a senior gynaecologist and obstetrician at Fortis La Femme Hospital in Bengaluru.
While these are the main symptoms which may point to the problem, not everyone may have all of them.
“As far as PCOS is concerned, it is important to diagnose it right. So not everybody who has irregular cycles has PCOS, not everybody who has pimples has PCOS, not everybody who has unwanted hair growth has PCOS. So PCOS is a combination of at least two of the three factors,” says Dr Aruna.
The weight ‘myth’
A symptom of PCOS that many gynaecologists point towards is erratic weight gain in a short period of time. It leads to a misconception that the weight of women with PCOS lie on the heavier side of the scale. This is not true, says Dr Aruna.
“It's not necessary that everyone who has PCOS is on the obese side. They can be thin as well. There is thin PCOS and obese PCOS and in general, a woman with PCOS puts on a lot of weight around her middle,” she says.
In fact, Dr Aruna says that thin PCOS is something that needs to be watched out for, since this is a case where the woman or the girl has a lot of hidden fat.
It may also happen that other symptoms are ignored, often being attributed to their habits or the usual broad term, ‘lifestyle’. There are dangers of PCOS going undetected.
“Not having cycles every 40-45 days puts you at risk. The inner layer of your uterus can become thick and can lead to abnormal growth in the endometrium. It is also a predisposing factor for endometrial cancer. You cannot go for months on end without periods,” Dr Chitra Selvan, an endocrinologist at Bengaluru’s Ramaiah Medical College.
“Is this PCOS?”
The most important thing before a diagnosis of PCOS, Dr Chitra says, is to eliminate the conditions the symptoms could mimic.
“There many conditions which look like PCOS. The most common of it is hypothyroidism. Hypothyroidism is extremely common and it can mimic PCOS but the thing is, if you correct the hypothyroidism, your PCOS should become normal,” says Dr Chitra. “Another (hormone disorder) is hyperprolactinemia. This is also very common these days, most probably due to medicines which are taken very commonly for gastritis, any other headache, antidepressants or antipsychotics. They can all cause prolactin to increase and can present symptoms that are exactly like PCOS.”
This is where a visit to a gynaecologist becomes important to diagnose PCOS correctly.
“I think the most important thing that most patients with PCOS don't get is that just having PCOS itself is a risk factor for developing more dangerous disorders in the future, like diabetes, hypertension or dyslipidemia. There is also evidence to suggest that women with PCOS are more at risk for heart disease,” Dr Chitra adds.
It takes around two years from the time of a girl’s first period for her cycles to settle down. If she faces irregularities during the first two years or gets pimples that are associated with that age, it is not called PCOS. According to Dr Chitra, every woman above the age of 20 should get a test done.
“Anybody who is more than 20 years [in age] should get their sugars, cholesterol and blood pressure checked annually. If you have a member in your family who has thyroid disorders, I would throw that in every year as well. If you have a child who is chubby and has not started her cycles till 15 years of age, then you'll have to get the child tested. But probably the most important junction where you should get all your tests done is before you plan your pregnancy,” Dr Chitra says.
PCOS, unfortunately, is not curable. A woman diagnosed with PCOS has to deal with the symptoms through her reproductive years and the next step is to make active changes in order to bring the symptoms under control.
Measures
Every woman who has been diagnosed with PCOS needs a long-term follow up, both doctors maintain. They suggest that the woman keep her lifestyle as a priority to make sure that she doesn't lose track of what she needs to achieve.
The first thing that both doctors suggest is mindful eating. “You stick to a staple food but the quantities can be changed. More than anything else, it's the importance of regularity that needs to be emphasized. So, it's not completely cutting of what you're used to but making certain changes in the proportions and being regular with it and being mindful when you're eating,” Dr Aruna says.
To start off, Dr Chitra says that one should make small changes in their food intake, starting with the meals that can be fixed easily — breakfast and snack at 4 pm.
“4 pm is what I call the weakest time of the day. It's when you make the most stupid food choices for the day. You're exhausted from the day and you know that your dinner is going to be very late, around 8-9 pm. And to think that you can get through that hour without a snack is never going to happen, because at 5 pm you are going to get hungry and then grab the next thing which is available, which is mostly not healthy at all,” she says.
A solution to this, she says, is to carry a nutbox or a fruit which can be consumed at 4 pm to take care of the hunger pangs.
The next step that patients need to take is physical activity and attempt to be more active during the day.
For this, Dr Chitra suggests that instead of taking on draining workouts which can hamper functionality during the day, it’s better to take a walk each day for around 30–45 minutes, and some classes of something a bit more intense (like zumba) during the week.
While these are measures that most patients of PCOS are advised, many women who have been diagnosed with PCOS are prescribed Oral Contraceptive Pills (OCPs) to tackle the hormone imbalance. OCPs pause your body’s hormone production and oestrogen is supplied to the body through these pills. While these pills are prescribed, “we wouldn't start the pill on every person who's been diagnosed with PCOS. It depends on what is the issue. Is it regularisation that she requires pills for, is she sexually active, does she need contraception, is she having a lot of acne for which she needs a certain kind of pill to reduce it? So all these have to be taken into consideration,” Dr Aruna says. Typically, OCPs are initially prescribed for around three to six months.
Both doctors say that PCOS is not something that affects a woman’s libido, and while it is a factor that affects chances of pregnancy, it can be mitigated. Dr Chitra says that the tests must taken before one plans their pregnancy, rather than after.
But PCOS doesn’t necessarily vastly limit a woman's chances of getting pregnant.
“With PCOS, the chances of getting pregnant are fairly good because some of the cycles are ovulatory. It is not that all the cycles are anovulatory in many ladies with PCOS. But, it is the best problem of infertility to have — to get a proper treatment to get positive results. Not having a baby can be because of many different reasons and PCOS is only one of them, the most common one of them,” Dr Aruna adds.
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