For women struggling with irregular menstrual cycles, proper diagnosis is vitally important to finding the best treatment options. There are many factors that can cause a woman’s period to be abnormal, including using birth control pills, having an IUD, excessive exercise, stress, weight loss, pregnancy, breastfeeding, thyroid disorders, uterine fibroids, and PCOS.
How Do PCOS and Uterine Fibroids Relate?
Women may experience changes in their menstrual cycle due to one or more of these conditions, and the causes can often change over time. For example, women diagnosed with PCOS at a young age may eventually develop uterine fibroids and begin to experience heavier and more frequent cycles in their 30s and 40s. For this reason, significant changes in the menstrual cycle should prompt women to visit their healthcare providers and investigate new causes for the change.
Uterine fibroids affect up to 80% of all women, so it is inevitable that we will find overlap with patients who also have PCOS. In fact, according to the Black Women’s Health Study at Boston University,
Women with PCOS are 65% more likely than other women to develop uterine fibroids over time.
Here we look at how PCOS is diagnosed and treated and how the development of uterine fibroids can affect treatment options.
What Is PCOS?
Polycystic Ovarian Syndrome (PCOS) affects 6-8% of women of child-bearing age and is characterized by excess hair growth, irregular menstrual cycles, obesity, and infertility. Typically, symptoms begin in adolescence, not long after the first menstrual cycle. When symptoms are subtle, however, diagnosis of PCOS can be challenging and may not be uncovered until later in life when infertility becomes apparent.
PCOS is a syndrome of excessive androgens or male hormones. It is perfectly normal for women to have small amounts of male hormones like testosterone, DHEAS, and androstenedione, but in higher amounts, they can lead to some unsightly male sexual characteristics, disrupt the menstrual cycle, and affect ovulation. It is not clear why these hormones are present at higher levels in women with PCOS, but genetics would be a likely suspect.
What Are the Symptoms of PCOS?
Excess male hormones in a woman can lead to changes in the female body that mimic male puberty. Women can start growing excessive, thick, dark hair in locations considered typical for male hair growth, including the upper lip, chin, below the belly button, and around the nipples. This is called hirsutism. Other symptoms include troublesome acne, male-pattern balding, increased muscle mass, developing a deeper voice, and enlargement of the clitoris.
Hormonal abnormalities in PCOS directly affect ovulation and the menstrual cycle, representing a significant source of infertility. High levels of androgens in women lead to the stimulation of too many eggs within each ovary. The eggs start to develop but stop growing too soon and fail to be released from the ovary or ovulate. This leads to no ovulation in some women and only occasional ovulation in others. When infertility is present, medications like Clomiphene or Letrozole can be given to stimulate eggs to complete their development and release from the ovary on time.
2. Menstrual Problems
When ovulation doesn’t happen, the balance of normal female hormones is also disrupted. There is a high level of estrogen relative to progesterone, and these hormones stop cycling. When there is no variation of female hormones, the uterus does not get the regular signal to have a normal menstrual cycle. Cycles may skip altogether, or they may be delayed. Menstrual cycles are unpredictable and can be either light or heavy. Spotting in between periods can also occur.
3. Pregnancy Complications
Women with PCOS who do get pregnant can have normal pregnancies, however, there are increased risks of certain pregnancy complications. These include high blood pressure, gestational diabetes, early labor, and preeclampsia, a rare disorder that can cause seizures.
4. Metabolic Disorders
Another feature of PCOS is a frequent link to metabolic syndrome. This condition is characterized by obesity, high cholesterol, high blood sugar, and high blood pressure. These signs and symptoms are associated with the body’s inability to use insulin efficiently, and these women may eventually develop type 2 diabetes mellitus. In this group, there is also an increased risk of developing sleep apnea, eating disorders, and depression or anxiety.
How Is PCOS Diagnosed?
Diagnosis of PCOS is made with a clinical evaluation, typically by your primary care physician. Often ultrasound of the pelvis will be performed, and women with PCOS will typically have enlarged ovaries with many follicles, or partially developed eggs, at the edges of the ovary. While this appearance is common in PCOS, it can also be seen in women without the condition.
Because of this, diagnosis is more certain when clinical evaluation shows that women are not ovulating and there are signs and symptoms of excess male hormones or androgens.
How Is PCOS Treated?
Treatment of PCOS for women who are not interested in actively getting pregnant typically involves hormonal medications like birth control pills that regulate the menstrual cycle. These medications can be prescribed to give a better balance of estrogen and progesterone. Depending on the type of medication and dose, this will give a signal to the ovaries and uterus to either cycle more normally or not at all. For women who are trying to get pregnant, there are medications to stimulate ovulation.
Other treatments are directed toward the conditions that come about with PCOS. Diet, exercise, and medications like metformin can be used to help with obesity and metabolic syndrome. Certain cosmetic treatments, like hair electrolysis, are also available to reduce the effects of hirsutism.
Unfortunately, these hormonal medications that help regulate cycles and control symptoms in women with PCOS carry some risks. Especially for women over 35 who smoke or have high blood pressure, heart disease, or obesity, there is an increased risk of developing dangerous blood clots that can lead to heart attacks and/or pulmonary embolism, both of which are life-threatening. These medications may need to be adjusted or changed over time. Fortunately, as women approach menopause, androgen levels, the culprit in PCOS, naturally decrease and cycles can become more normal.
Can You Have PCOS and Fibroids at the Same Time?
For women with irregular menstrual cycles who have been diagnosed with PCOS, gradual changes in the amount and frequency of bleeding may happen over time. Periods may become more or less frequent. For women who start to experience heavier or more frequent cycles or bleeding in between cycles, evaluation of other conditions is recommended.
Women with PCOS are 65% more likely to develop uterine fibroids, which grow slowly over time and thrive in PCOS where estrogen levels often remain high relative to progesterone. An ultrasound, which can be performed at an OB/GYN office or an imaging center, is typically the first step in this evaluation. When uterine fibroids are diagnosed and can be linked with symptoms like frequent, heavy menstrual cycles, pelvic pain, or urinary frequency, other treatment options may be considered.
What Treatment Options Are There for Patients with PCOS and Fibroids?
The hormonal medications that treat PCOS can often help control symptoms of uterine fibroids initially. However, fibroids will typically continue to slowly grow over time if there is enough estrogen present in the body. As fibroids get larger, symptoms like heavy menstrual bleeding, pelvic pain, and urinary frequency may no longer be adequately treated with medication.
When this is the case, fibroids can often be treated with a non-surgical procedure called uterine fibroid embolization (UFE). This safe and well-established treatment, performed by interventional radiologists, is more than 90% effective in controlling major symptoms related to uterine fibroids. There is a lower risk of complication than with surgeries like myomectomy and hysterectomy, and recovery time for UFE is much shorter than after surgery. The majority of women who are suffering from uterine fibroids, even when also being treated for PCOS, are candidates for UFE.
If you are experiencing fibroid-related symptoms or are interested in learning more about how uterine fibroid embolization may help you, please contact the Atlanta Fibroid Center®. Dr. John Lipman and Dr. Mitchell Ermentrout have over 35 years of experience combined in treating fibroids with UFE. They have helped thousands of women regain their quality of life. Do not settle for suffering in silence. With a quick 45-minute procedure and a week of recovery, you can be done with painful fibroid symptoms forever.