Polycystic Ovarian Syndrome

Polycystic ovarian syndrome is the name given to a cluster of symptoms which a woman might have due to a hormone imbalance. In this post we will be discussing this topic in detail.

Reena always felt tired, no matter how well she slept. Weight had started creeping up despite she practically starving herself. Cycles were getting delayed, her previously clear face had started breaking out into pimples. There were days when she didn’t know ,why but she just felt sad.

What was happening to her…..everybody wondered……while the cysts in her ovaries had a wicked laugh……..

In 1721 an Italian scientist described a married, infertile woman with shiny ovaries with a white surface and the size of pigeon eggs. The man was never taken seriously until 1935 where two scientists Stein and Leventhal described the same findings as a disease named after themselves. The diagnosis of the Polycystic Ovarian syndrome as we know of it today has undergone a sea of change even since then. Why am I giving you history? It is just for you to understand that a very common problem, with wide ranging medical implications, seemingly simple on the outside, yet it has managed to baffle scientists for years and even today we know some but not all the answers.  

What might be those symptoms that we are talking about?

• Irregular menstrual cycle. Women with PCOS may miss periods or have fewer than eight periods in a year). Rarely their periods may come every 21 days or more often. Some women with PCOS stop having menstrual periods.
• Too much hair on the face, chin, or parts of the body where men usually have hair. This is called “hirsutism.” Hirsutism affects up to 70% of women with Polycystic Ovarian syndrome . 
• Acne or pimples on the face, chest, and upper back
• Thinning hair or hair loss on the scalp, a very typical male-pattern baldness
• Weight gain or difficulty in losing weight
• Darkening of skin, particularly along neck creases, in the groin, and underneath breasts
• Skin tags, which are small excess flaps of skin in the armpits or neck area

Along with this there may or may not be difficulty in conceiving, increased risk of miscarriages, increased risk of gestational diabetes in pregnancy and some other long-term complications which I will discuss later in the podcast. 

Then what is PCOD?

PCOD or polycystic ovarian disease is often used interchangeably with Polycystic Ovarian syndrome or PCOS and does not mean anything different. PCOD is an old term that was used years ago and has now been given up because the term suggested that PCO is a disease, which it is not. The ovary gets enlarged in size, become pearly white, the outer layer becomes thicker and there are small fluid filled sacs or cysts arranged underneath the thick outer surface and also throughout the substance of the ovary. This feature is seen when doing an ultrasound especially a vaginal ultrasound wherein these follicles or cysts are arranged like a ring just beneath the surface…almost like a necklace of pearls and that’s how it is described on ultrasound. 

How common is it and why does it happen?

Around the world, one in every 10 women are likely to suffer from this problem but Asians seem to have a unique affinity towards this syndrome and almost 20% women will manifest one or the other symptoms of Polycystic Ovarian syndrome . 

There is probably a genetic link to the inheritance of Polycystic Ovarian syndrome and thus we see mothers with pcos having daughters who also have similar problems when they grow up. There is another theory as well which talks about the environmental and other factors which might work on the foetus while it is still inside the mother’s womb and that causes certain changes which might lead the girl developing pcos later in life. Whatever be the theory, the start is always while the girl is in the womb. Even though the women may have the ‘pcos gene’ so to say, she may or may not manifest the symptoms of the diseases till much later in life. Imagine a switch in the brain for each of the symptoms or problems related to pcos. Depending on lifestyle changes, weight gain, stress, pregnancy etc one or the other switch gets flicked on or off. Thus, someone who was thin, had regular periods and had no other symptoms may start having delayed periods and acne after her child is born probably owing to the weight gain in pregnancy. It is so common to see women with delayed periods starting to get regular cycles the moment they lose weight. 

When I tell patients that their pcos might be inherited, they almost quip that their mothers never had the problem, or that conception or irregular periods was never the issue with them.

I have two ways to explain this. Firstly, our mothers and grandmothers have different lifestyle factors working for them and that could be a reason why they may not have manifested. Secondly in the same family itself if a woman has 3 daughters, different switches may get flicked on for each woman. The mother may show no symptoms, while one daughter may have just delayed periods, another one is thin and has severe facial hair and the last one has obesity and diabetes. The point I am trying to drive home is that just because you have the genetic predisposition of developing pcos does not mean you will have any problems with it. it will largely also depend on your lifestyle and environment that decides which features cause you more trouble. 

I am not going to get into details of the disease process inside the body but there is something called insulin resistance that you should about. Insulin resistance is present in almost 70 to 80% of women with Polycystic Ovarian syndrome (PCOS). The glucose in our body is driven into the cells by a hormone called insulin. If, however there is insulin resistance the glucose can’t be utilized and thus sugar levels might go up and to overcome this problem the body will try and produce more insulin and thus its levels will also go up. This excess of insulin acts on the ovary in women and produces excess of 2 hormones LH and testosterone or the male hormone. Almost all problems related to Polycystic Ovarian syndrome (pcos) can be explained via the abnormal behaviour of these hormones. The insulin resistance leads to women having a higher tendency towards diabetes, discolouration of skin and skin tags. The excess of LH hormone prevents ovulation while the excess male hormone causes hair fall, or excess facial hair, pimples and weight gain especially around the hips and belly. Obesity and vitamin D deficiency further increases insulin resistance thus making it a vicious cycle. 

There are some other short term and long-term problems associated with Polycystic Ovarian syndrome that we need to be aware of:

1. Hypothyroidism or under functioning of the thyroid gland is common in women with pcos.
2. Polycystic Ovarian syndrome itself and the associated thyroid gland dysfunction leads to elevation of the prolactin hormone secretion. This in turn may lead to milky secretion from the breast as well as delayed periods and infertility. 
3. Infertility: because of the abnormal LH hormone levels, insulin resistance, obesity and thick capsule over the ovarian surface, ovulation is sometimes premature, often delayed and in some instances does not happen altogether. Thus, the woman finds it difficult to conceive.
4. Miscarriage: the abnormal glucose levels, fluctuating hormones, obesity and something called luteal phase defect wherein the womb is unable to support the pregnancy all may lead to higher chances of miscarriages.
5. Gestational diabetes chances increase because of the inability to utilize the glucose. To know more about this please listen to the podcast on “battling blood sugars in pregnancy’ 
6. Diabetes. More than half of women with PCOS will have diabetes or prediabetes (glucose intolerance) before the age of 40.4 Learn more about diabetes on our Diabetes page.
7. High blood pressure. Women with PCOS are at greater risk of having high blood pressure compared with women of the same age without PCOS. High blood pressure is a leading cause of heart disease and stroke. 
8. Unhealthy cholesterol. Women with PCOS often have higher levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol. High cholesterol raises your risk of heart disease and stroke.
9. Sleep apnoea. This is when momentary and repeated stops in breathing interrupt sleep. Many women with PCOS have overweight or obesity, which can cause sleep apnoea. Sleep apnoea raises your risk of heart disease and diabetes.
10. Depression and anxiety. Depression and anxiety are common among women with Polycystic Ovarian syndrome .
11. Endometrial cancer. Problems with ovulation, obesity, insulin resistance, and diabetes increase the risk of developing cancer of the endometrium (lining of the uterus or womb).

How do we diagnose Polycystic Ovarian syndrome ?

A diagnosis of PCOS can be made when at least two of the following three criteria are met:

1. Irregular periods or no periods

2. Higher levels of androgens or male hormones are present in the blood shown by:

• a blood test, OR
• symptoms such as:
  • excess facial or body hair growth
  • scalp hair loss
  • acne.

3. Polycystic ovaries are visible on an ultrasound, meaning:

• more than 20 follicles (partly developed eggs) are visible on one or both ovaries or
• the size of one or both ovaries is increased (more than 10ml).

You do not need to have an ultrasound if you have criteria 1 and 2.

The ultrasound should ideally be a vaginal ultrasound as that way the probe is closest to the ovary and can pick up the features. In case of abdominally done ultrasound because of the less sensitivity and abdominal obesity, sometimes the findings in the ovary can be missed. This is the reason why in an unmarried young probably obese adolescent girl, sometimes the diagnosis is missed on ultrasound. 

Before we move ahead with the treatment, I would like to address some myths and questions that I frequently encounter in my practise:

1. I need to have a baby as soon as I get married since I have pcos
   1. That’s not true. Yes, pcos may cause difficulty in conceiving but that again is not true for every woman or even most of the women. As long as you maintain a healthy lifestyle and weight, there is no reason you should have more problems.
2. I will need to have an IVF done to have a baby since I have pcos
   1. Similar answer as before. Most women who look after their health well, will have normal conceptions. Few will need higher treatment like intra uterine insemination and still fewer will need an IVF.
3. I hardly eat anything, thus I my diet is not the problem. Why do I need a nutritionist?
   1. It is true that the weight gain in pcos is mostly genetic and aggravated by hormonal imbalance. But to treat the problem, a diet under supervision of an expert is absolutely necessary. Diet may not be the problem, but it’s definitely the solution.
4. I took medicines for pcos and my doctor said my pcos is cured now.
   1. Pcos as I have explained before is linked to the genetic makeup. You can’t change that. the symptoms may change, the problems may come and go but the background pcos status is there to stay.
5. I did an ultrasound last year and I was diagnosed with PCOS and this year I repeated the scan to check the status and I was told it’s gone.
   1. This is simply a myth. The reasons it wasn’t seen this year could be a different doctor who couldn’t pick it up on scan, or the scan machine itself being different and not of good quality, it could happen if an abdominal scan is done or simply if one doesn’t clear bowels and has too much of abdominal gas on the day of scan.
   2. Yes, there is one situation where the scan could earlier show a the typical ovarian feature of PCOS and in subsequent years that is missing on scan. The cysts seen on scan are nothing, but fluid filled cavities that are meant to contain eggs. over the years as the number of eggs reduce or disappear this look on ultrasound will also disappear but that again will not change the disease process inside the body of the probability of having problems like diabetes, heart disease etc. also from a fertility perspective this seemingly ‘curing of pcos’ may in fact be a scary sign that the number of eggs are dwindling fast.
6. I don’t have the typical feature on a vaginal ultrasound. Thus, I have been told I don’t have pcos. 
   1. Wrong again. As I explained in the diagnosis, only 2 of the 3 features need to be present. Thus, even if the scan does not show the typical ovarian features, pcos may still be there.
7. I am thin thus I can’t have pcos and even if I do, I guess I won’t have any problems because I am thin

1. Women with pcos are more commonly obese but they can be thin as well.
2. These women have their own set of problems. Yes, it’s true they are more blessed than those who are overweight but since in the thin people, weight loss does not help, its sometimes more difficult to treat these women.
3. I have regular periods; how can I have pcos.
   1. The reason for me making this podcast is to make you aware of the basic nature of this disease and once you understand that, you will yourself be able to answer most questions yourself. Now for this myth about periods, if you simply refer to the diagnosis criteria of two out of 3 features, you will have the answer yourself. 

I know this podcast is getting long, but this disease deserves every minute that we can devote to it. despite it being common and there being zillions of doctors and blogs and nutritionists dealing with it, there are probably even more numbers of myths, confusions and wrong treatments associated with it.

Before I even start talking of treatment understand that 70% of this treatment is in your hands and only 30% is in mine. This 30% comprises of diagnosing associated problems like thyroid disorder, prolactin excess etc which could prevent you from losing weight even if you try and also helping you at difficult crossroads where you have given your 100% and tried everything honestly yet are stuck either with weight or pimples or infertility.

Let’s start with the 70% first. It has been shown that even if a woman loses just 5% of her existing body weight, a lot of her problems of pcos will start to get better. Easier said than done. Women with pcos find it extremely difficult to lose weight and if they are not consistent then it all bounces back. That is why she needs to maintain her lifestyle changes and use a gynaecologists’ help wherever her weight gets stuck. I am no nutritionist and the topic of diet in such women probably needs an entire podcast by itself. I will probably make one shortly. But in a nutshell, since glucose metabolism is a problem, such women need to reduce carbohydrate intake and increase protein intake. Exercise needs to be calorie burning and consistent. I am currently in the process of making yet another podcast on what constitutes exercise and hopefully shall air that too soon. Meanwhile in short, one needs to understand there is no shortcut to this success so take out those running shoes, fish out the skipping ropes, enrol in a Zumba class or practise krav maga and start sweating it out and don’t stop even if you manage to lose weight and don’t stop even if you don’t lose a gram. Consistency is the key. We need to keep adding layer. Exercise then diet then medical evaluation, nutritional supplements and finally disease modification and control with medicines. Himmat karne walon ki kabhi har nahi hoti…..remember that.

Regarding the medical part, I have already spoken about diagnosing thyroid and prolactin issues and correcting them. ……………….Vitamin D levels need to be good otherwise weight loss won’t happen and neither will sugar levels normalize.

Natural supplements like myoinositol, de chiro inositol, chromium and zinc amongst others are useful in controlling pcos. They are available in the form of tablets to be consumed regularly and without any side effects.

Beyond this treatment needs to be specific and need based. For someone who desires fertility, a bit of weight loss, prevention of miscarriages or control of blood sugars, metformin is a brilliant drug that is safe and effective. It is sold as an anti-diabetes medicine, but it has a certain beauty. It does not reduce the sugars in those that have normal sugars but does that only in diabetics. It is not habit forming and wont also lead to you developing diabetes later in life. We can easily leave the drug once the desired effect has happened. 

There are specialized oral contraceptive pills available that cut down the male hormone thus regularizing periods, removing acne, making the skin less oily, helping weight loss contrary to popular belief and even making the periods more regular. 

Sometimes we use both metformin and oral contraceptives when desired weight loss is not happening with one. 

For excess facial hair that is not controlled with oral contraceptives or if someone doesn’t suit them, there are specific tablets that stop hair growth and help immensely. They might need to be combined with laser treatment to remove the existing hair. 

Lastly this podcast can’t be complete without busting one more myth and that is of the role of laparoscopy…………………. For those of you who don’t know, laparoscopy is the process of putting a telescope through the belly button into the tummy and operating from there. ………………..Since the outer surface of the ovary gets very thick in women with pcos, it is thought that during laparoscopy if we make multiple holes with the help of an electric current into the surface of the ovary then the severity of the problem reduces, release of eggs which wasn’t happening earlier, starts to happen and the woman conceives easily. Every word of this is true but only with certain riders:

1. The effect of drilling lasts only about 6 months at the most thus understand that it can’t cure the problem. 
2. ……………The act of drilling using electric current wont damage the ovary in women with pcos but in a woman who already has compromised ovarian reserve, the drilling can be disastrous.
3. As per guidelines it must never be done for an unmarried girl or even a married woman who is not wanting fertility treatment as it doesn’t have long term benefits and may damage ovaries if done over zealously
4. It can be done if the woman has delayed periods, has elevated LH levels and is either not willing to use injections to make eggs or there is a danger that using injections might cause her some harm or that injections were used but they were ineffective. Thus there are very few specific indications where this tool should be used. Even in these cases there is a rule of 4 which is to be followed by us laparoscopic surgeons to ensure minimum damage.

The pros and cons of the procedure must be clearly discussed with your doctor before you go ahead with it. 

No one said its easy being a woman and I always maintain women are multi-tasking warriors who fight their own battles every day while maintaining a calm countenance on the outside and being there and being around for every person in her life and family. 

As a doctor I cant promise we will remove the pain of PCOS from your system but we can certainly lessen your load. For that we need your cooperation and your faith………….. Lastly a word to the men out there again…..trust me every time I create a podcast dealing with an issues that women face, I realise how lucky we are to have such tough souls in our lives who suffer silently every day with one problem or another ……..yet always willing to put a smile on our faces. If you agree with me, maybe you could do something for the important women in your life today or simply say a thank you and an I love you and am sure that will take their pain away and make their day. 

Reena always felt tired, no matter how well she slept. Weight had started creeping up despite she practically starving herself. Cycles were getting delayed, her previously clear face had started breaking out into pimples. There were days when she didn’t know ,why but she just felt sad.

What was happening to her…..everybody wondered……while the cysts in her ovaries had a wicked laugh……..

In 1721 an Italian scientist described a married, infertile woman with shiny ovaries with a white surface and the size of pigeon eggs. The man was never taken seriously until 1935 where two scientists Stein and Leventhal described the same findings as a disease named after themselves. The diagnosis of the Polycystic Ovarian syndrome as we know of it today has undergone a sea of change even since then. Why am I giving you history? It is just for you to understand that a very common problem, with wide ranging medical implications, seemingly simple on the outside, yet it has managed to baffle scientists for years and even today we know some but not all the answers.  

Polycystic ovarian syndrome is the name given to a cluster of symptoms which a woman might have due to a hormone imbalance.

What might be those symptoms that we are talking about?

• Irregular menstrual cycle. Women with PCOS may miss periods or have fewer than eight periods in a year). Rarely their periods may come every 21 days or more often. Some women with PCOS stop having menstrual periods.
• Too much hair on the face, chin, or parts of the body where men usually have hair. This is called “hirsutism.” Hirsutism affects up to 70% of women with PCOS. 
• Acne or pimples on the face, chest, and upper back
• Thinning hair or hair loss on the scalp, a very typical male-pattern baldness
• Weight gain or difficulty in losing weight
• Darkening of skin, particularly along neck creases, in the groin, and underneath breasts
• Skin tags, which are small excess flaps of skin in the armpits or neck area

Along with this there may or may not be difficulty in conceiving, increased risk of miscarriages, increased risk of gestational diabetes in pregnancy and some other long-term complications which I will discuss later in the podcast. 

Then what is PCOD?

PCOD or polycystic ovarian disease is often used interchangeably with PCOS and does not mean anything different. PCOD is an old term that was used years ago and has now been given up because the term suggested that PCO is a disease, which it is not. The ovary gets enlarged in size, become pearly white, the outer layer becomes thicker and there are small fluid filled sacs or cysts arranged underneath the thick outer surface and also throughout the substance of the ovary. This feature is seen when doing an ultrasound especially a vaginal ultrasound wherein these follicles or cysts are arranged like a ring just beneath the surface…almost like a necklace of pearls and that’s how it is described on ultrasound. 

How common is it and why does it happen?

Around the world, one in every 10 women are likely to suffer from this problem but Asians seem to have a unique affinity towards this syndrome and almost 20% women will manifest one or the other symptoms of PCOS. 

There is probably a genetic link to the inheritance of PCOS and thus we see mothers with pcos having daughters who also have similar problems when they grow up. There is another theory as well which talks about the environmental and other factors which might work on the foetus while it is still inside the mother’s womb and that causes certain changes which might lead the girl developing pcos later in life. Whatever be the theory, the start is always while the girl is in the womb. Even though the women may have the ‘pcos gene’ so to say, she may or may not manifest the symptoms of the diseases till much later in life. Imagine a switch in the brain for each of the symptoms or problems related to pcos. Depending on lifestyle changes, weight gain, stress, pregnancy etc one or the other switch gets flicked on or off. Thus, someone who was thin, had regular periods and had no other symptoms may start having delayed periods and acne after her child is born probably owing to the weight gain in pregnancy. It is so common to see women with delayed periods starting to get regular cycles the moment they lose weight. 

When I tell patients that their Polycystic ovarian syndrome might be inherited, they almost quip that their mothers never had the problem, or that conception or irregular periods was never the issue with them.

I have two ways to explain this. Firstly, our mothers and grandmothers have different lifestyle factors working for them and that could be a reason why they may not have manifested. Secondly in the same family itself if a woman has 3 daughters, different switches may get flicked on for each woman. The mother may show no symptoms, while one daughter may have just delayed periods, another one is thin and has severe facial hair and the last one has obesity and diabetes. The point I am trying to drive home is that just because you have the genetic predisposition of developing pcos does not mean you will have any problems with it. it will largely also depend on your lifestyle and environment that decides which features cause you more trouble. 

I am not going to get into details of the disease process inside the body but there is something called insulin resistance that you should about. Insulin resistance is present in almost 70 to 80% of women with pcos. The glucose in our body is driven into the cells by a hormone called insulin. If, however there is insulin resistance the glucose can’t be utilized and thus sugar levels might go up and to overcome this problem the body will try and produce more insulin and thus its levels will also go up. This excess of insulin acts on the ovary in women and produces excess of 2 hormones LH and testosterone or the male hormone. Almost all problems related to Polycystic ovarian syndrome can be explained via the abnormal behaviour of these hormones. The insulin resistance leads to women having a higher tendency towards diabetes, discolouration of skin and skin tags. The excess of LH hormone prevents ovulation while the excess male hormone causes hair fall, or excess facial hair, pimples and weight gain especially around the hips and belly. Obesity and vitamin D deficiency further increases insulin resistance thus making it a vicious cycle. 

There are some other short term and long-term problems associated with PCOS that we need to be aware of:

1. Hypothyroidism or under functioning of the thyroid gland is common in women with Polycystic ovarian syndrome .
2. Polycystic ovarian syndrome (PCOS) itself and the associated thyroid gland dysfunction leads to elevation of the prolactin hormone secretion. This in turn may lead to milky secretion from the breast as well as delayed periods and infertility. 
3. Infertility: because of the abnormal LH hormone levels, insulin resistance, obesity and thick capsule over the ovarian surface, ovulation is sometimes premature, often delayed and in some instances does not happen altogether. Thus, the woman finds it difficult to conceive.
4. Miscarriage: the abnormal glucose levels, fluctuating hormones, obesity and something called luteal phase defect wherein the womb is unable to support the pregnancy all may lead to higher chances of miscarriages.
5. Gestational diabetes chances increase because of the inability to utilize the glucose. To know more about this please listen to the podcast on “battling blood sugars in pregnancy’ 
6. Diabetes. More than half of women with Polycystic ovarian syndrome (PCOS) will have diabetes or prediabetes (glucose intolerance) before the age of 40.4 Learn more about diabetes on our Diabetes page.
7. High blood pressure. Women with Polycystic ovarian syndrome (PCOS) are at greater risk of having high blood pressure compared with women of the same age without PCOS. High blood pressure is a leading cause of heart disease and stroke. 
8. Unhealthy cholesterol. Women with PCOS often have higher levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol. High cholesterol raises your risk of heart disease and stroke.
9. Sleep apnoea. This is when momentary and repeated stops in breathing interrupt sleep. Many women with PCOS have overweight or obesity, which can cause sleep apnoea. Sleep apnoea raises your risk of heart disease and diabetes.
10. Depression and anxiety. Depression and anxiety are common among women with Polycystic ovarian syndrome.
11. Endometrial cancer. Problems with ovulation, obesity, insulin resistance, and diabetes increase the risk of developing cancer of the endometrium (lining of the uterus or womb).

How do we diagnose PCOS?

A diagnosis of PCOS can be made when at least two of the following three criteria are met:

1. Irregular periods or no periods

2. Higher levels of androgens or male hormones are present in the blood shown by:

• a blood test, OR
• symptoms such as:
  • excess facial or body hair growth
  • scalp hair loss
  • acne.

3. Polycystic ovaries are visible on an ultrasound, meaning:

• more than 20 follicles (partly developed eggs) are visible on one or both ovaries or
• the size of one or both ovaries is increased (more than 10ml).

You do not need to have an ultrasound if you have criteria 1 and 2.

The ultrasound should ideally be a vaginal ultrasound as that way the probe is closest to the ovary and can pick up the features. In case of abdominally done ultrasound because of the less sensitivity and abdominal obesity, sometimes the findings in the ovary can be missed. This is the reason why in an unmarried young probably obese adolescent girl, sometimes the diagnosis is missed on ultrasound. 

Before we move ahead with the treatment, I would like to address some myths and questions that I frequently encounter in my practise:

1. I need to have a baby as soon as I get married since I have pcos
   1. That’s not true. Yes, Polycystic ovarian syndrome may cause difficulty in conceiving but that again is not true for every woman or even most of the women. As long as you maintain a healthy lifestyle and weight, there is no reason you should have more problems.
2. I will need to have an IVF done to have a baby since I have pcos
   1. Similar answer as before. Most women who look after their health well, will have normal conceptions. Few will need higher treatment like intra uterine insemination and still fewer will need an IVF.
3. I hardly eat anything, thus I my diet is not the problem. Why do I need a nutritionist?
   1. It is true that the weight gain in Polycystic ovarian syndrome is mostly genetic and aggravated by hormonal imbalance. But to treat the problem, a diet under supervision of an expert is absolutely necessary. Diet may not be the problem, but it’s definitely the solution.
4. I took medicines for pcos and my doctor said my pcos is cured now.
   1. Pcos as I have explained before is linked to the genetic makeup. You can’t change that. the symptoms may change, the problems may come and go but the background pcos status is there to stay.
5. I did an ultrasound last year and I was diagnosed with PCOS and this year I repeated the scan to check the status and I was told it’s gone.
   1. This is simply a myth. The reasons it wasn’t seen this year could be a different doctor who couldn’t pick it up on scan, or the scan machine itself being different and not of good quality, it could happen if an abdominal scan is done or simply if one doesn’t clear bowels and has too much of abdominal gas on the day of scan.
   2. Yes, there is one situation where the scan could earlier show a the typical ovarian feature of Polycystic ovarian syndrome is the name given to a cluster of symptoms which a woman might have due to a hormone imbalance. and in subsequent years that is missing on scan. The cysts seen on scan are nothing, but fluid filled cavities that are meant to contain eggs. over the years as the number of eggs reduce or disappear this look on ultrasound will also disappear but that again will not change the disease process inside the body of the probability of having problems like diabetes, heart disease etc. also from a fertility perspective this seemingly ‘curing of pcos’ may in fact be a scary sign that the number of eggs are dwindling fast.
6. I don’t have the typical feature on a vaginal ultrasound. Thus, I have been told I don’t have pcos. 
   1. Wrong again. As I explained in the diagnosis, only 2 of the 3 features need to be present. Thus, even if the scan does not show the typical ovarian features, pcos may still be there.
7. I am thin thus I can’t have pcos and even if I do, I guess I won’t have any problems because I am thin

1. Women with pcos are more commonly obese but they can be thin as well.
2. These women have their own set of problems. Yes, it’s true they are more blessed than those who are overweight but since in the thin people, weight loss does not help, its sometimes more difficult to treat these women.
3. I have regular periods; how can I have pcos.
   1. The reason for me making this podcast is to make you aware of the basic nature of this disease and once you understand that, you will yourself be able to answer most questions yourself. Now for this myth about periods, if you simply refer to the diagnosis criteria of two out of 3 features, you will have the answer yourself. 

I know this podcast is getting long, but this disease deserves every minute that we can devote to it. despite it being common and there being zillions of doctors and blogs and nutritionists dealing with it, there are probably even more numbers of myths, confusions and wrong treatments associated with it.

Before I even start talking of treatment understand that 70% of this treatment is in your hands and only 30% is in mine. This 30% comprises of diagnosing associated problems like thyroid disorder, prolactin excess etc which could prevent you from losing weight even if you try and also helping you at difficult crossroads where you have given your 100% and tried everything honestly yet are stuck either with weight or pimples or infertility.

Let’s start with the 70% first. It has been shown that even if a woman loses just 5% of her existing body weight, a lot of her problems of pcos will start to get better. Easier said than done. Women with pcos find it extremely difficult to lose weight and if they are not consistent then it all bounces back. That is why she needs to maintain her lifestyle changes and use a gynaecologists’ help wherever her weight gets stuck. I am no nutritionist and the topic of diet in such women probably needs an entire podcast by itself. I will probably make one shortly. But in a nutshell, since glucose metabolism is a problem, such women need to reduce carbohydrate intake and increase protein intake. Exercise needs to be calorie burning and consistent. I am currently in the process of making yet another podcast on what constitutes exercise and hopefully shall air that too soon. Meanwhile in short, one needs to understand there is no shortcut to this success so take out those running shoes, fish out the skipping ropes, enrol in a Zumba class or practise krav maga and start sweating it out and don’t stop even if you manage to lose weight and don’t stop even if you don’t lose a gram. Consistency is the key. We need to keep adding layer. Exercise then diet then medical evaluation, nutritional supplements and finally disease modification and control with medicines. Himmat karne walon ki kabhi har nahi hoti…..remember that.

Regarding the medical part, I have already spoken about diagnosing thyroid and prolactin issues and correcting them. ……………….Vitamin D levels need to be good otherwise weight loss won’t happen and neither will sugar levels normalize.

Natural supplements like myoinositol, de chiro inositol, chromium and zinc amongst others are useful in controlling pcos. They are available in the form of tablets to be consumed regularly and without any side effects.

Beyond this treatment needs to be specific and need based. For someone who desires fertility, a bit of weight loss, prevention of miscarriages or control of blood sugars, metformin is a brilliant drug that is safe and effective. It is sold as an anti-diabetes medicine, but it has a certain beauty. It does not reduce the sugars in those that have normal sugars but does that only in diabetics. It is not habit forming and wont also lead to you developing diabetes later in life. We can easily leave the drug once the desired effect has happened. 

There are specialized oral contraceptive pills available that cut down the male hormone thus regularizing periods, removing acne, making the skin less oily, helping weight loss contrary to popular belief and even making the periods more regular. 

Sometimes we use both metformin and oral contraceptives when desired weight loss is not happening with one. 

For excess facial hair that is not controlled with oral contraceptives or if someone doesn’t suit them, there are specific tablets that stop hair growth and help immensely. They might need to be combined with laser treatment to remove the existing hair. 

Lastly this podcast can’t be complete without busting one more myth and that is of the role of laparoscopy…………………. For those of you who don’t know, laparoscopy is the process of putting a telescope through the belly button into the tummy and operating from there. ………………..Since the outer surface of the ovary gets very thick in women with pcos, it is thought that during laparoscopy if we make multiple holes with the help of an electric current into the surface of the ovary then the severity of the problem reduces, release of eggs which wasn’t happening earlier, starts to happen and the woman conceives easily. Every word of this is true but only with certain riders:

1. The effect of drilling lasts only about 6 months at the most thus understand that it can’t cure the problem. 
2. ……………The act of drilling using electric current wont damage the ovary in women with pcos but in a woman who already has compromised ovarian reserve, the drilling can be disastrous.
3. As per guidelines it must never be done for an unmarried girl or even a married woman who is not wanting fertility treatment as it doesn’t have long term benefits and may damage ovaries if done over zealously
4. It can be done if the woman has delayed periods, has elevated LH levels and is either not willing to use injections to make eggs or there is a danger that using injections might cause her some harm or that injections were used but they were ineffective. Thus there are very few specific indications where this tool should be used. Even in these cases there is a rule of 4 which is to be followed by us laparoscopic surgeons to ensure minimum damage.

The pros and cons of the procedure must be clearly discussed with your doctor before you go ahead with it. 

No one said its easy being a woman and I always maintain women are multi-tasking warriors who fight their own battles every day while maintaining a calm countenance on the outside and being there and being around for every person in her life and family. 

As a doctor I cant promise we will remove the pain of PCOS from your system but we can certainly lessen your load. For that we need your cooperation and your faith………….. Lastly a word to the men out there again…..trust me every time I create a podcast dealing with an issues that women face, I realise how lucky we are to have such tough souls in our lives who suffer silently every day with one problem or another ……..yet always willing to put a smile on our faces. If you agree with me, maybe you could do something for the important women in your life today or simply say a thank you and an I love you and am sure that will take their pain away and make their day. 

Also read:  First Fertility Consultation – Tips for best consult 

This brings me to the end of yet another discussion. This discussion is also available as a podcast – check out here.

This podcast is available on Apple and Google podcast as well as Spotify. Do subscribe and leave your comments and suggestions on the Apple podcast app. That’s the only way we can make this better. 😊 Looking forward to great interactions…. keep listening.

If you get a chance do look up my website www.drrajeevagarwal.co.in and YouTube channel in my name.

Do email me on fertilitywithoutborders@gmail.com if you have any queries or if you want me to create a podcast on any topic of your choice.