Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder among women of reproductive age, affecting about 6–20% or roughly 1 in 15 reproductive aged women worldwide.[1,2] While the cause of PCOS remains unclear, it is linked to a combination of unfavorable inherited factors such as early sexual development and environmental factors including physical inactivity and a poor diet.[1]
Women are diagnosed with PCOS if they have any two of the following symptoms:
Hyperandrogenism: Excessive levels of testosterone and other androgens, which lead to features like acne or excess facial and body hair.
Ovulatory dysfunction: Irregular or absent ovulation, which results in irregular or missed periods and fertility challenges.
The presence of ovarian cysts: These are multiple small fluid-filled sacs in the ovaries, visible through an ultrasound.[2]
But the symptoms and effects of PCOS are not limited to these — PCOS can affect nearly every aspect of a woman’s health, including metabolic and heart health, fertility, mental well-being, and physical appearance.[2] One important feature of PCOS is hormonal imbalance as this not only contributes to the condition but can also worsen its symptoms.
This article covers key hormones that are altered in PCOS and the impact on the body.
Testosterone and other androgens
Women naturally produce five types of androgens: dehydroepiandrosterone sulphate (DHEAS), dehydroepiandrosterone (DHEA), androstenedione, testosterone, and dihydrotestosterone (DHT). These hormones are produced in the adrenal glands and ovaries. Among them, testosterone and DHT are the most active.[2]
Although androgens are often thought of as male hormones, they serve important functions in women too. They contribute to muscle and bone growth, support sexual libido, and promote the development of pubic and underarm hair. However, women require only small amounts of androgens for these purposes. Most of the androgens in the body are converted to estrogen.[2]
About 60–80% of women with PCOS produce excessive amounts of androgens, especially testosterone produced in the ovaries. This overproduction leads to a condition called hyperandrogenism.[2]
Hyperandrogenism can cause a range of physical symptoms, including:
Acne
Excessive body and facial hair growth (hirsutism)
Scalp hair loss (alopecia)
Excess fat around the midsection (central obesity)
Thick, darkened skin patches around creases and folds (acanthosis nigricans).[1]
Beyond physical changes, hyperandrogenism disrupts ovarian function. It prevents eggs (ova) from maturing fully, leading to the formation of ovarian cysts. This affects ovulation, causes irregular periods, and makes conception challenging for women with PCOS.[1,2]
Insulin
Insulin plays a vital role in the body by regulating the supply of glucose to various organs based on their energy needs. However, in some women with PCOS, key organs like the muscles, liver, and fat tissues do not respond well to insulin. This phenomenon is known as insulin resistance. As a result of insulin resistance, glucose delivery to these organs falls short of their demands.[3.4]
Insulin resistance is common in PCOS, affecting around 65–95% of women with the condition.[3] While insulin resistance is typically associated with being overweight or obese, women with PCOS experience insulin resistance regardless of their weight, whether they are obese, overweight, or even of normal weight.[5]
The body compensates for insulin resistance by producing more insulin, leading to a condition called hyperinsulinemia.[3.4] This excess insulin drives the ovaries to produce more testosterone, disrupting the normal development of eggs and contributing to symptoms like irregular periods and infertility. Hyperinsulinemia and insulin resistance also alter the lining of the womb, and increase the risk of developing metabolic, heart, and mental health conditions.[3.5]
Gonadotropin releasing hormone, luteinizing hormone, and follicle stimulating hormone
These hormones are released in rhythmic bursts from the brain throughout the day to regulate the functions of the ovaries. Gonadotropin-releasing hormone (GnRH) controls the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In turn, FSH and LH control ovarian functions, such as egg development, ovulation, and hormone production.[4.6]
Among women with PCOS, the frequency of GnRH release increases, favoring the release of LH over FSH.[4.6] This hormonal shift raises the LH-to-FSH ratio up to two or three times higher than the typical 1:1 ratio seen in women without PCOS.[4]
This imbalance in LH-to-FSH disrupts normal ovarian processes. It stimulates excessive testosterone production in the ovaries, prevents eggs from fully maturing, and impairs ovulation.[4,6] Beyond the reproductive health consequences, a high LH-to-FSH ratio is linked to increased risks of insulin resistance, type 2 diabetes, obesity, and heart conditions.[4]
Anti-Müllerian hormone
Anti-Müllerian hormone (AMH) is produced by developing eggs in the ovaries after puberty. Its production gradually declines and stops after menopause. This hormone aids and regulates the development of eggs during each reproductive cycle. Also, levels of AMH are closely tied to the ovarian reserve — the approximate number of eggs remaining in the ovaries. Hence, AMH testing is used in fertility clinics to assess a woman's reproductive health.[7]
For women with PCOS, AMH levels are typically two to four times higher than normal. This is because women with PCOS tend to have a higher number of eggs that begin developing but never fully mature. These eggs remain in an early stage of development, known as the antral stage, and are not released during ovulation. Since eggs in the antral stage continue to produce AMH, the abundance of these immature eggs leads to elevated AMH levels in women with PCOS. As a result, AMH levels can sometimes be used to diagnose PCOS or monitor the condition's progression.[7]
Elevated AMH levels in PCOS further contribute to hormonal imbalances by boosting the production of GnRH, LH, and testosterone. Additionally, AMH interacts with LH to delay or even halt the maturation of eggs at the antral stage, which, in turn, raises AMH levels even further.[7]
Estrogen and progesterone
Estrogen and progesterone are two of the primary reproductive hormones produced in the ovaries. Like AMH, these hormones are also produced in the ovaries. In women with PCOS, estrogen levels may be slightly elevated, due to several factors. For one, the small, immature eggs that don’t undergo ovulation continue to produce estrogen.[2,6] Additionally, excessive androgen produced in PCOS is converted into estrogen by an enzyme called aromatase, found in fat tissues. [1]
On the other hand, women with PCOS tend to have low progesterone levels. This is because progesterone is normally produced after ovulation, which may not occur regularly in PCOS. As a result of this, progesterone production may be insufficient.[6]
The imbalance between estrogen and progesterone has significant effects on the body. High estrogen levels suppress the production FSH, which in turn prevents ovulation.[2] Normally, progesterone helps balance the effects of estrogen on the womb, but in PCOS, the low levels of progesterone fail to counteract the high estrogen. This can lead to endometrial hyperplasia, an overgrowth of the cells lining the womb. If left untreated, endometrial hyperplasia can increase the risk of endometrial cancer. Additionally, low progesterone levels can interfere with pregnancy, as this hormone is essential for maintaining a pregnancy. [6]
Managing Hormonal Imbalance in PCOS
There are different methods of managing hormonal imbalance in PCOS, including making lifestyle changes, taking medications or supplements, or using alternative treatments. These treatments are usually tailored to the symptoms of PCOS a woman has and her health goals.
1. Lifestyle Changes
Women with PCOS are usually advised to adopt a healthy lifestyle aimed at losing weight or maintaining a healthy weight. This can be achieved through regular exercise, having a balanced diet, and avoiding a sedentary lifestyle. Maintaining a healthy weight can not only lower androgen levels and improve hormonal imbalance but also improve ovulation, insulin sensitivity, blood sugar levels, and mental health of women with PCOS. A low caloric diet rich in proteins, whole foods, fiber, and healthy fats can also support hormonal balance. It is important to avoid refined sugars, unhealthy fats, and processed foods as they can worsen insulin resistance and hormonal imbalance.[8]
2. Medications
For many women with PCOS, medications are used to regulate hormones and address specific symptoms. Birth control pills are commonly prescribed to balance estrogen and progesterone levels, regulate periods, and reduce excess hair growth. Metformin, a drug used for managing insulin resistance, can help lower insulin and androgen levels and improve ovulation. Anti-androgens like spironolactone and statins are sometimes used to reduce symptoms of hyperandrogenism, such as acne and excessive hair growth.[8,9,10]
3. Supplements
Certain supplements may help support hormonal balance and improve PCOS symptoms as additional treatments. Inositol, particularly myo-inositol and d-chiro-inositol, has been shown to improve insulin sensitivity and regulate menstrual cycles. Vitamin D may also help improve insulin resistance, ovulatory dysfunction, and irregular menstrual cycle.[10]
4. Alternative Treatments
Herbal remedies are commonly used by women as complementary treatments for PCOS because they have beneficial effects and little effects. Some herbs used include cinnamon and marjoram. They may help to regulate the menstrual cycle and reduce insulin resistance.[8]
It is important to approach the use of supplements and herbal remedies with caution and under the guidance of a healthcare provider. Your healthcare provider will typically offer you the best treatment plan according to your needs and health goals.
References
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Melin J, Forslund M, Alesi S, Piltonen T, Romualdi D, Spritzer PM, et al. Metformin and combined oral contraceptive pills in the management of polycystic ovary syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab [Internet]. 2023 Aug 9 [cited 2024 Dec 21];109(2):e817–36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10795934/
Islam H, Masud J, Islam YN, Haque FKM. An update on polycystic ovary syndrome: A review of the current state of knowledge in diagnosis, genetic etiology, and emerging treatment options. Womens Health (Lond) [Internet]. 2022 Aug 16 [cited 2024 Dec 21];18:17455057221117966. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9386861/ Assessed and Endorsed by the MedReport Medical Review Board