Ovarian Cysts and Polycystic Ovarian Syndrome (PCOS): What You Need to Know

This post is going to be mainly about PCOS, but let me get ovarian cysts out of the way first.

I recently gave a presentation to a bunch of primary care providers and explained the significance of ovarian cysts: It means the patient is female. And what about a family history of ovarian cysts? It means the patient has female relatives. There were some laughs and nods. I do not mean to completely dismiss ovarian cysts as they can be very painful. But a history of ovarian cysts means absolutely nothing to a gynecologist. It is kind of like telling an orthopedic surgeon that you have twisted your ankle in the past.

When I order ultrasounds for reasons unrelated to ovarian concerns, i.e. to locate an IUD, the radiologist will almost always mention ovarian cysts, which usually causes unnecessary anxiety. The good radiologists have learned to change their description to read “follicle” for small cysts. Sounds much less threatening and I am a firm believer in semantics.

The following is intentionally simplified–there are lots of different types of cysts and I am only describing the most common type. A cyst happens when a woman ovulates, and the vast majority of women ovulate monthly. These cysts can be painful and problematic when they do not release the egg as they are supposed to, and then grow larger. They can become especially painful when they rupture, which is one way that they resolve without treatment. The vast majority of ovarian cysts go away without any intervention.

What about ovarian cancer? I have seen thousands of ovarian cysts in my career, and I can count on one hand how many were cancer. There are subsets of cysts that do not resolve, such as dermoid cysts that contain hair and teeth, which leads to a chief complaint of “Ewww, get this thing out of me ASAP!” But I will leave these to another post.

Polycystic Ovarian Syndrome (PCOS)

Let me start by recommending that you ignore the name PCOS, because it is very misleading. PCOS is a hormonal problem, not an ovarian cyst problem. It is caused by relatively high androgens (male hormone) and/or insulin-resistance.

Depending on which criteria are used, 5-10% of women have PCOS. Like so many syndromes, PCOS is a constellation of disorders and the severity is on a spectrum. The classic example of a woman with PCOS is obese, has thick dark hair where she least desires it, has greasy skin and acne, and very irregular periods. Most women with PCOS have some but not all of these symptoms.

Many patients are frustrated by the lack of universal criteria or tests that are specific for PCOS. Do I have PCOS or not???

Well, do you have PCOS?

The diagnosis is most commonly made using the Rotterdam Criteria, published in 2003. A woman must have 2 of the following 3 symptoms to make the diagnosis:

  • Irregular periods, less than 9 per year
  • Androgen excess, as demonstrated by hirsutism (hair where you don’t want it) or acne
  • An ultrasound showing lots (at least 12) small follicles (cysts) on the periphery of the ovaries.

It is this last finding that gives the syndrome it’s most common name. As you can see, having lots of small ovarian cysts is not diagnostic, just one of 3 common findings. Other criteria are used by various organizations, but the Rotterdam Criteria is the most common. Let’s tackle each of these.

Irregular periods

Most women with PCOS have a life-long history of irregular periods. They report that their periods have been sporadic and unpredictable since they were teens, and only were normal if they were on the pill. When I see a woman in her 20s who was having regular periods and now all of a sudden she skips several months, I need to rule-out other causes before assuming PCOS. Other causes include thyroid disease, over-exercising or weight loss, or a high prolactin level. Simple blood tests can rule-out most of these causes.

Obesity

Obesity is a common feature of PCOS. Some believe PCOS causes obesity and some believe obesity causes PCOS. It is a bit of a chicken and egg conundrum, but I believe a little of both: PCOS makes weight loss more difficult but not impossible. Unfortunately, weight loss is key to improving symptoms. Because PCOS is related to insulin-resistance, women with PCOS are at much higher risk of developing full-blown diabetes, which makes weight loss even more crucial.

High Androgens

This is demonstrated by acne and/or abnormal hair growth. Abnormal hair growth can be too much (hirsutism) or too little–having a mustache or dark hair on your chest versus male-pattern baldness. But not every women with these symptoms has PCOS. Ethnicity and genetics definitely play a role in hair growth, and other conditions can lead to acne. This is why it is one of three criteria for PCOS.

How one treats PCOS depends on severity of symptoms and ultimate goals. Do you want to conceive? Improve your acne? Prevent long term issues like diabetes? I will cover this all in a separate post.

My aim with this post is clarification: ovarian cysts and PCOS are very different entities. Ovarian cysts are (usually) the unfortunate result of ovulation gone awry and are a temporary condition. PCOS is a more chronic hormonal abnormality.

 

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