evidence of obesity or type 2 diabetes, these associated conditions should be treated earlier. Obesity is known to be associated with increased insulin levels, and this effect is magnified during early puberty. Fasting insulin is more than three times higher in the obese group. This effect is also seen during late puberty and adulthood, but not with such a marked difference. Testosterone levels are also likely to be higher in overweight adolescents. For example, in one study, 93.8 percent of obese preteens were found to have elevated testosterone levels versus 0 percent of the non-obese group.9
Differential diagnoses
Hyperandrogenism and polycystic ovaries are not exclusive to PCOS, so other diseases that mimic PCOS must be excluded by history or by physical or laboratory examination before the diagnosis can be confirmed. While most of these conditions are rare, they may be serious and require entirely different treatments, which makes the distinction important. The list of similar conditions includes
·pregnancy,
·hyperprolactinemia (prolactin excess),
·thyroid disorders,
·nonclassic congenital adrenal hyperplasia (NCAH),
·Cushing’s Syndrome, and
·hyperandrogenemia (androgen excess, tumor/drug-induced) Let us consider some of these other conditions.
» Pregnancy
Pregnancy is by far the most common cause of menstrual irregularity. Obviously, a simple pregnancy test, either a home test or laboratory confirmation, is mandatory before confirming the diagnosis of PCOS. It would be very embarrassing to miss this simple diagnosis.
» Hyperprolactinemia
Prolactin is a hormone normally secreted by the pituitary gland in the brain that enables mammals, including humans, to produce milk. Prolactin levels normally increase toward the end of pregnancy for proper breast development in preparation for breastfeeding. Excessive prolactin in the blood when a woman is not pregnant is known as hyperprolactinemia.
A wide range of conditions may lead to hyperprolactinemia, including chronic kidney or liver disease, drug use, and thyroid disease. Another common cause is a small tumor (microadenoma) of the pituitary gland, which may oversecrete prolactin into the blood. The diagnosis of hyperprolactinemia is made by measuring the blood level of prolactin.
High prolactin levels may mimic PCOS by inhibiting estrogen and causing menstrual irregularities and difficulty with ovulation. Symptoms that may help differentiate the disease include breast enlargement and abnormal milk production.
» Thyroid disorders
The thyroid is a small gland at the front of the neck. It secretes thyroid hormone, which controls many aspects of metabolism. Too little thyroid in the body may cause weight gain, menstrual irregularities, infertility, and hair loss that may be confused with PCOS. The diagnosis of thyroid disorders is made by measuring the blood levels of the thyroid hormones (TSH, T3, T4) to rule out this easily treated condition.
» Nonclassic congenital adrenal hyperplasia
Androgens are normally produced in both the ovaries and the surface (cortex) of the adrenal glands. In rare situations, the adrenal glands overproduce androgens, resulting in a syndrome called nonclassic congenital adrenal hyperplasia (NCAH), which is reminiscent of PCOS, with irregular menstruation, hirsutism, and acne. It is a rare genetic disorder that can affect young girls and women, and there is no commonly used diagnostic test for it.
» Cushing’s Syndrome
Prolonged exposure to high levels of the hormone cortisol causes Cushing’s Syndrome. In some cases, tumors oversecrete cortisol. In other cases, this syndrome can be caused by synthetic cortisol (prednisone), which is used to treat autoimmune diseases (asthma, lupus) and to suppress the immune system during organ transplants. Elevated cortisol levels can cause weight gain, menstrual irregularities, and infertility, which may be confused with PCOS. While prolonged periods of stress or athletic overtraining may increase cortisol, these circumstances almost never do so to the degree that’s necessary to develop Cushing’s Syndrome.
Cushing’s Syndrome presents with some characteristic symptoms that can help to distinguish it from PCOS. These include a pocket of fat that develops below the nape of the neck (a buffalo hump), stretch marks (striae), thinning skin, muscle weakness and atrophy, sensitivity to infections, decreases in bone density, and severe psychiatric and cognitive dysfunction. The diagnosis of high cortisol levels is made by taking a small blood sample.
» Hyperandrogenemia
Tumors in the adrenal glands or ovaries may oversecrete androgens causing hirsutism, clitoral enlargement, deepening of the voice, and male-pattern baldness. These tumors are extremely rare but potentially life-threatening. The average age of diagnosis is 23.4 years, which overlaps significantly with the age range for PCOS. Tumors typically produce far higher levels of androgen than are found in PCOS, leading to far more severe symptoms. The diagnosis of these tumors is usually made by looking at an image from a computerized tomography (CT) scan of the abdomen.
Drug-induced androgen excess is usually associated with those surreptitiously taking testosterone, mostly to enhance athletic performance. Because patients may not always admit to the use of these drugs, a high index of suspicion is necessary to make the diagnosis.
When I was diagnosed with PCOS, I checked the boxes for all three of the diagnostic criteria, even though only two out of three are necessary for the diagnosis. I had frank PCOS, the most severe phenotype, and I was devastated by this news. Today, I know there is a natural way to reverse even the worst PCOS. By understanding the underlying root cause of the syndrome, we can treat it rationally and successfully.
Who Gets PCOS?
.................
THE PREVALENCE OF PCOS, using the NIH criteria, ranges from 6 to 9 percent, with a strikingly similar rate globally.1 Using the Rotterdam criteria, that rate is about 15 to 20 percent of women. This makes PCOS the most common endocrine (hormonal) disorder of young women by far. Approximately one in 15 women in the United States are affected, with similar proportions in Spain, Greece, and the United Kingdom. An estimated 105 million women of childbearing age are afflicted worldwide.
GENETICS AND PCOS
TO TRY TO understand why some people develop PCOS and others don’t, researchers usually begin by looking for genetic influences. A large Dutch study comparing sets of identical twins with sets of fraternal twins found that approximately 70 percent of PCOS may be attributed to genetic influences.2 A U.S. study found that sisters of patients diagnosed with PCOS are more likely to have symptoms, with an estimated 22 percent also fulfilling the full diagnostic criteria.3 A further 24 percent of sisters had hyperandrogenism but regular menstrual cycles, likely indicating that they too had mild PCOS. In a separate study, mothers of patients with PCOS had higher androgen levels, insulin resistance, and metabolic syndrome.4 First-degree relatives, male or female, are more likely to have evidence of insulin resistance. Despite these strong genetic tendencies, no single gene has been identified as the causative factor. This indicates that PCOS is a complex genetic disorder with multiple genes contributing small degrees of risk.
