without PCOS.22 Approximately 30 percent of women with PCOS have evidence of liver damage by blood tests. In women of reproductive age investigated for NAFLD, 71 percent also had PCOS. Like PCOS, the occurrence of NAFLD is highly associated with metabolic syndrome.23
NAFLD is often underdiagnosed because there are virtually no symptoms of the disease. It is really only through blood tests that the condition is discovered. Thus, it is important to screen for this condition.
» Sleep apnea
Obstructive sleep apnea (OSA) is a condition in which the upper airway collapses during sleep. Patients cannot breathe for an instant, which causes them to wake up momentarily, though they usually don’t remember. Regular sleep patterns are disrupted and sleep architecture is fragmented. The main symptoms of this disease include snoring and excessive daytime sleepiness.
The rate of OSA in women with PCOS is an astounding five to 30 times higher than in women without PCOS.24 Like PCOS, the occurrence of OSA is highly linked to metabolic syndrome.
» Anxiety and depression
Both anxiety and depression are common among patients with PCOS, and a high index of suspicion should be maintained. Abnormal male-pattern hair growth, acne, obesity, and menstrual irregularities destroy self-esteem, especially during adolescence. Depression, anxiety, and other psychological abnormalities are more prevalent among younger women with PCOS.25 Depression is also common among women suffering from infertility as well as chronic illnesses associated with PCOS (type 2 diabetes, cardiovascular disease, and cancer).26
Weight loss and lifestyle changes may improve the symptoms of PCOS as well as feelings of depression and anxiety.27 Clinicians should regularly assess for psychological well-being.
» Cancer
Women with PCOS are three times more likely to develop endometrial cancer and two to three times more likely to develop ovarian cancer when compared with the general population.28 Since there is a significant overlap between PCOS and obesity/hyperinsulinemia, it is no surprise that women with PCOS are also at higher risk of obesity-related cancers (such as breast cancer and colorectal cancer), which now make up 40 percent of all cancers as classified by the World Health Organization.29
» Diabetes
Perhaps the disease most closely associated with PCOS is type 2 diabetes, a disease of excessive insulin resistance, a trait shared by PCOS patients as well. An estimated 82 percent of women with type 2 diabetes have multiple cysts on their ovaries, and 26.7 percent fulfill the diagnostic criteria for PCOS.30 Women with PCOS have three times the risk of developing type 2 diabetes by menopause when compared with the general population. I was one of these women. A glucose tolerance test confirmed that I had developed type 2 diabetes.
Among women with PCOS, 23 to 35 percent will have prediabetes and 4 to 10 percent will have type 2 diabetes.31 This rate of prediabetes is three times higher than in women without PCOS. The rate of undiagnosed type 2 diabetes is 7.5- to 10-fold higher. As in the general population, the rate of type 2 diabetes among women with PCOS rises with increasing Body Mass Index. PCOS is recognized by the American Diabetes Association as a risk factor for diabetes.
Women with PCOS, particularly if obese, have a higher incidence of gestational diabetes and insulin resistance, a rate estimated to be about twice that of otherwise healthy women.32 Gestational diabetes increases the risk of miscarriage and delivering by cesarean section or induced birth, due to the increased size of the fetus.33 Developing diabetes during pregnancy increases a woman’s risk of developing type 2 diabetes, cardiovascular disease, and metabolic syndrome in the future. Maternal obesity also increases the baby’s risk of developing childhood obesity and PCOS.
Women with type 1 diabetes who are being treated with insulin are also at risk of PCOS, with an estimated 18.8 percent34 to 40.5 percent35 affected, compared with only 2.6 percent in the control group. PCOS is six to 15 times more common among women with type 1 diabetes, probably due to the frequent high dosage of insulin.
Women with PCOS should be screened for type 2 diabetes using an oral glucose tolerance test every three to five years. Measuring fasting glucose alone may miss the diagnosis of up to 80 percent of prediabetic patients and 50 percent of diabetic patients. If cardiovascular risk factors exist, the screening should be done annually so the disease can be diagnosed at an early stage when lifestyle measures such as dietary changes can prevent damage to the body’s major organs.
» Metabolic syndrome
In 1988, Dr. Gerald Reaven of Stanford University termed syndrome X as a group of conditions with an unknown common factor, “X.” These conditions included central obesity, high blood pressure, high triglycerides, and high blood glucose. Reaven and Dr. Ami Laws (also of Stanford University) published the book Insulin Resistance: The Metabolic Syndrome X36 linking insulin resistance to metabolic syndrome and calling it the common factor in all these seemingly separate conditions.
In 2002, a National Institutes of Health report37 defined a patient as having metabolic syndrome if three of the following five conditions are present:
·Abdominal obesity: over 40 inches (102 centimeters) for men; over 35 inches (89 centimeters) for women
·High blood glucose: over 100 milligrams/deciliter (mg/dL), or taking medication
·High triglycerides: over 150 mg/dL, or taking medication
·Low high-density lipoprotein (HDL): below 40 mg/dL for men, below 50 mg/dL for women, or taking medication
·High blood pressure: over 130 mmHg for the systolic (top) number, over 85 mmHg for the diastolic (bottom) number, or taking medication
General obesity, albeit commonly associated, is not one of the criteria. Approximately 25 percent of metabolic syndrome patients are non-obese individuals. Interestingly, high low-density lipoprotein (LDL or “bad” cholesterol) is also not a criterion, even though many doctors and professional guidelines obsess about LDL and statins.
The prevalence of metabolic syndrome in the adult American population is now estimated at 88 percent38—leaving only 12 percent as metabolically healthy—and this comes with an increased risk of cardiovascular disease, stroke, cancer, NAFLD, obstructive sleep apnea, and PCOS.
The link between metabolic syndrome and insulin resistance makes it a reversible dietary condition, not a chronic progressive disease.
UNDERSTANDING THE LINK BETWEEN PCOS AND ITS ASSOCIATED RISKS
PCOS MUST BE considered more than merely a disorder of excess facial hair, acne, and abnormal reproduction. Patients with PCOS have double the chance of being hospitalized compared with those without the disease. The United States spent an estimated $4 billion in 2004 on health care related to treating PCOS39—an amount equal to the entire gross domestic product of Barbados. Much of this cost (40.4 percent) is due to the associated type 2 diabetes.40
Even more sobering, this number likely underestimates the true costs, because it takes into account only the reproductive years and not the associated health risks such as type 2 diabetes, heart attacks, strokes, and cancer that may arise in the future. These diseases typically occur in a woman’s post-menopausal years and are many, many times more expensive than simply treating PCOS.
Furthermore, PCOS
