POLYCYSTIC ovarian syndrome (PCOS) may have evolved to protect women from famine thousands of years ago.
Now, PCOS is a syndrome that causes insulin resistance, which results in women putting on excess weight and a decrease in fertility rates. This is a theory Dr Alexandra Ames, from Ames Medical Services on Fitt Street, Port of Spain, told an audience of women and girls at her symposium on PCOS on July 3.
“There is a theory – and it is only a theory; it has not been proven – that women with PCOS hold on to their weight.
That is, they have a problem losing weight.
“You can imagine if there is a famine, you’re in Africa or India a few thousand years ago, and we are in a state of famine – it is actually the women who could hold on to their weight who could survive the famine. Even though they might have slightly reduced fertility, because they weren’t overweight, because they were in a famine, their PCOS symptoms were not as bad. They were able to ovulate and they would have children,” Ames said.
Globally, six to ten per cent of the female population have PCOS. PCOS is a common reproductive and endocrinologic disorder in women and girls and is higher among women of Afro-Caribbean, East Indian or Mediterranean heritage. PCOS symptoms include acne, irregular hair growth and irregular periods.
It can lead to infertility.
Insulin resistance is a major symptom of PCOS, causing women to put on weight. Though women were able to retain weight to survive famines in the past, because food is in abundance now, PCOS is more of a disorder than an evolutionary survival adaptation – particularly with the consumption of high-starch and sugar-rich foods. “They (women) would survive the pregnancy. Their children would survive further famines and they would have children. It was a genetic advantage – but what happens today? Are we in a state of famine?
“It is working against us in this day and age, but fast foods and sweet drinks, juices and high-calorie-packed things actually means we are going to put on weight. Unfortunately, what was advantageous in the past is working against us in today’s world,” she said.
A study by doctors from the University School of Medicine, Ankara and Izmir Institute of Technology, Izmir, Turkey, estimated that PCOS may have existed for more than 50,000 years. In their paper Evolutionary determinants of polycystic ovary syndrome: Part 1 they provide similar information which corroborates the theory Ames presented.
Ames describes insulin resistance as a cyclical problem where the PCOS causes women to put on weight, and the more they put on weight, the more insulin-resistant they become.
“In insulin resistance, when you have a meal with starch in it, the stomach breaks down starch or carbohydrates into its components, which are sugars – glucose. The stomach releases the glucose into the bloodstream, travels around the body and it is taken up by the cells in the brain and the muscles to be burned as fuel.
“The pancreas is a gland that sits behind the stomach, and when it knows the blood sugar has risen, it sends out this hormone known as insulin... Insulin is like the key that opens the lock of a door to allow the sugar to come out of the bloodstream and taken up as fuel,” she said.
With insulin resistance, a person is producing insulin, but the insulin is not working well. So the pancreas will send out more insulin. In the early stages of insulin resistance, someone can have a high blood level of insulin, but after many years of the pancreas having to work so hard, Ames says it gets tired and does not work as well.
“That is when it can no longer manage the blood glucose. That is when people start to get pre-diabetes or diabetes, when the blood sugar rises, so that’s the primary problem with PCOS: the insulin-resistance problem.”
Ames said insulin resistance leads to fertility problems among women: most women with PCOS can get pregnant, but they need help, and weight loss is the first recommendation for dealing with the syndrome.
“When you have the high blood level of insulin, it actually has an effect on the ovaries themselves. It causes some of the ovaries to produce too much of the excess male hormones, like testosterone.
“All women have some testosterone – it’s what gives us our sex drive. For some reason, this action of the high insulin level makes those cells of the ovaries produce more testosterone. The combination of the high testosterone and high insulin level affects how the ovaries ovulate. It affects that release, it happens with all the follicles on the outside: they are not able to release the egg, and when you don’t ovulate, you don’t get a period.
This is the reason why women with PCOS have a problem with reduced number of periods. She said if a woman or girl is not having a period often, the lining of the womb is not being shed, which is the point of a period. This lining will get thicker and thicker, and that increases the risk of endometrial cancer or cancer of the lining of the womb.
Not all women and girls with irregular periods or cysts on their ovaries have PCOS. They may have “pearls” around their ovaries or irregular periods or show signs of having excess male hormones in their body, but unless they have two out of the three criteria, it cannot be considered PCOS. These assessment measures are called the Rotterdam criteria.
“You have to have two out of the three. Either cysts, irregular periods, or clinical or biochemical evidence of excess male hormones. Clinical evidence would be severe acne – teenage-boy-type acne – and male-pattern hair growth – hair on the face and chest. Some women might have a condition called clitoromegaly (an enlarged clitoris but it is very rare), because of this excess testosterone. Even if you don’t have that, sometimes we can even measure the level of free testosterone. That can be elevated out of the usual range for women.”
She said a woman can have polycystic ovaries without having the syndrome.
“I’ve seen people who think they have polycystic ovarian syndrome because they have done a scan and the scan came back describing polycystic ovaries. Just because you have a number of cysts on the scan does not mean you have the syndrome. Bearing that in mind, lots of women have acne and do not have PCOS, or unwanted hair; sometimes women have irregular periods and don’t have PCOS.”
A person with is PCOS 40 per cent more likely to get type two diabetes. Ames describes PCOS as a cyclical problem with weight loss.
“The high insulin level actually causes us to put on weight. It is a vicious cycle. You have the insulin levels causing the excess male hormones, and the high insulin level cause weight gain, and weight gain actually causes insulin resistance to become worse. So you get more of the male hormone and more of the acne and more of the unwanted hair and more of the problems with cysts on the ovaries and more of the problem with infertility.”
PCOS cannot be cured, but doctors and dietitians can prescribe treatments and meal plans to help control the symptoms.
“How do we treat PCOS? Weight loss, weight loss, weight loss, because the weight loss helps you to reduce your insulin resistance. It was the high levels of the insulin in the first place that cause the problem. If we could lose weight and lower our levels of insulin, then we could have a fighting chance. Diet and exercise – it helps your own insulin to work better as well and helps you to lose weight,” she said.
Ames suggested anyone who suspects they have PCOS should visit a gynaecologist, and those diagnosed should seek advice from a dietitian and dermatologist to manage the symptoms.