PCOS, or polycystic ovary syndrome is a complex condition that the more you learn about the more questions you have about it.

There are a number of factors that make understanding PCOS more complicated than other conditions. They include:

1) The highly individual nature of PCOS - the fact that PCOS may manifest differently in just about every woman who has it.
2) The complex nature of how your endocrine (hormonal) system works. As it’s always looking for balance (homeostasis) when one hormone goes haywire it often causes other hormones to also go out of balance.
3) The fact there are most likely at least 4 types of PCOS.

In this article, I am going to deep dive into the most common symptoms of PCOS and their underlying causes. I hope this sheds a little light on the condition for you.

Common PCOS Symptoms & Their Cause:

1) Irregular or absent periods

One of the early warning signs of PCOS is experiencing irregular or absent (amenorrhea) periods. Normally speaking, periods can come about every 21 to 40 days. But, many women with PCOS can go months without having a period.

This can be dangerous as shedding your uterine lining (your period) is extremely healthy for the female body. During a ‘normal’ menstrual cycle, the endometrium, the innermost lining layer of the uterus is exposed to certain hormones such as estrogen, which cause the lining to proliferate and thicken.

When ovulation does not occur, the lining is not shed and is exposed to higher levels of estrogen, causing the endometrium to grow much thicker than normal. This is what contributes to the increased risk of endometrial cancer. This is also one of the reasons doctors are often quick to prescribe hormonal birth control for women with PCOS.

But, how and why exactly is PCOS causing issues with your menstrual cycle?

An example of how PCOS can impact your menstrual cycle.

It’s all got to do with the hormonal imbalances that PCOS creates. Here’s how a ‘healthy’ menstrual cycle works in a nutshell.

1) Your brain sends down follicle-stimulating hormone (FSH) which triggers a number of your follicles (where your eggs live) to start to mature.
2) One follicle will start to properly mature, as this follicle matures it releases estrogen (this is your main source of estrogen).
3) As the follicle matures more, it releases more estrogen, once it reaches a certain level in your bloodstream your brain picks up on this and senses that the follicle is near full maturation.
4) Your brain now sends down a surge of luteinizing hormone (LH) and this surge is what triggers ovulation - where your follicle ruptures and releases its egg for possible fertilization
5) This leftover follicle that has just released it’s egg is now called the corpus luteum, which is now your source of progesterone, which is very important if fertilization occurs.
6) Both estrogen and progesterone fall away dramatically, leading to the shedding of the uterine lining (your period). It then starts all over again.

So, as you can see, your menstrual cycle relies on a delicate balance of hormones - FSH, estrogen, LH, and progesterone. But, like everything in the human body it can also be impacted by outside forces - such as other hormones.

Most women with PCOS will have excessive amount of androgen hormones (male sex hormones such as testosterone) and this imbalance negatively impacts the delicate hormonal balance of your menstrual cycle.

High androgen levels cause constant high levels of LH - what impact does this have? When LH levels are too high early in the cycle, and not just in the surge just before ovulation, it means that FSH cannot properly mature your follicle.

This is what’s called follicular arrest, and is actually the cause of polycystic ovaries in PCOS. It means that a number of follicles mature slightly and stay half-matured. You can see this on an ultrasound and will show as multiple cysts like follicles.

So, high levels of androgens cause an imbalance of menstrual cycle hormones that throws the menstrual cycle out of balance. Therefore, to regulate your menstrual cycle you must lower androgen (testosterone) levels to a normal range.

2) Fertility Problems

Fertility issues are also directly tied to menstrual cycle irregularities. As I just mentioned, if you’re not ovulating regularly, it’s just going to make trying to fall pregnant far harder. High androgen levels impact the regular growth of your eggs and the release of them - needed for ovulation.

And if ovulation does occur, these hormonal imbalances can also prevent the lining of your uterus from developing properly to allow for implantation of the mature egg. It’s also incredibly important to focus on hormonal balance while you’re pregnant and not just while you’re trying to fall pregnant.

PCOS is associated with higher risks for early term pregnancy loss and gestational diabetes. Following a healthy holistic lifestyle for your entire term is of the utmost importance to you and baby.

Once again, to maximise your fertility chances you must address the hormonal imbalances that are limiting your fertility efforts currently. This will involve:

- Understanding what’s driving your androgen excess (is it ovarian or adrenal androgen excess?)
- Improving your insulin resistance
- Making sure your nutrient levels are optimal

3) Acne

Acne is not something that only women with PCOS may struggle with so, it’s entirely possible that your acne is not being caused specifically by PCOS but, in this article I only want to focus on how PCOS can cause acne.

PCOS-related acne is once again caused by excess androgens. A way to think about it is to compare it to men who take steroids. The steroids men take are simply synthetic testosterone so, it means that they have excess amounts of androgens in their system - just like the majority of women with PCOS. Obviously, these women are not taking steroids - I just want to make this easy to understand.

So, think about the side effects men may experience from taking steroids? Acne, balding/hair loss, excessive hair growth, mood issues such as anxiety or depression - these are the same symptoms excess androgen levels can cause for women with PCOS.

High androgen levels can trigger acne by over-stimulating oil glands. These glands are inside the pores of your skin, and they produce an oil called “sebum.” Sebum carries dead skin cells from follicles to your skin’s surface, but when there is too much of it, follicles become clogged and pimples can emerge.

4) Thinning Hair And Hair Loss (Androgenic Alopecia)

Once again, thinning hair or hair loss on the scalp of your head is a result of excess levels of androgens. Your hair grows in a cycle with the actual hair growing about 0.3mm to 0.4mm each day, which adds up to around six inches per year. However, not all of the hair follicles are growing new hair at the same time.

Hair growth occurs in a cycle. At any given time, each strand is in a different part of the cycle. It’s a good thing that each of our hair’s cycles are not in sync, otherwise we would shed all of our hair at once! This means throughout the year your hair is in a constant cycle of growing and replacing hair. It’s why when you brush your hair some will fall out and get stuck on your brush but, because you are always growing more you don’t notice hair loss on your head.

Excess androgens negatively impact your hair growth cycle as it shortens the ‘anagen’ growing phase. It also lengthens the time between the shedding of a hair and the start of a new anagen phase.

This means it takes longer for hair to start growing back after it is shed in the course of the normal growth cycle. The hair follicle itself also changes, shrinking and producing a shorter, thinner hair shaft, a process called "follicular miniaturization." As a result, thicker, pigmented, longer-lived terminal hairs are replaced by shorter, thinner, non-pigmented vellus hairs.

5) Male-Like Hair Growth (Hirsutism)

Hirsutism is excessive hair growth on the face or body. On women it is seen as coarse, dark hair that will usually appear on the face, chest, abdomen, back, upper arms, or upper legs. Hirsutism is a symptom of excessive amounts of androgen hormones in the female system. PCOS is the most common cause of hirsutism.

There are a few parts of your body that are especially sensitive to androgen hormones, these body parts are generally the upper lip, breasts, chin/jaw, lower stomach, inner thighs, and lower back. Your chest, upper stomach, and upper back are less hormone sensitive. This is why, generally speaking, hirsutism will affect these areas in women with PCOS.

High androgen levels in your system can cause some vellus (soft, fine, generally colorless) hairs in these areas to actually change and become terminal (long, coarse, dark) hairs. Unfortunately, excess androgen levels can have the opposite effect on the scalp, leading to female pattern baldness which I spoke about in the last point.

6) Weight Gain

Just like acne, weight gain isn’t specific to PCOS with up to 70% of the general population being classed as overweight or obese. Important point though: they use the BMI to make these judgments and the BMI is ridiculous - don’t get me started.

Weight gain specific to PCOS is related to insulin resistance (IR) - a condition that around 70% of all women with PCOS will have. I’ll explain quickly how insulin resistance works. Normally, insulin is released after a meal to regulate your blood sugar levels.

It does this by shuttling the energy and nutrients in your bloodstream into the cells of your body that need them to function properly. In IR, the cells no longer react to insulin normally, insulin cannot get the cells open - leading to a dangerous buildup of insulin (hyperinsulinemia) and sugar hyperglycemia in your bloodstream.

Your body cannot have this so it dumps large numbers of sugar into your fat cells - leading them to increase in size, or potentially duplicate. The result? Weight gain. So, here’s how insulin resistance leads to weight gain for women with PCOS.

1) It stores a larger portion of the energy (calories) your intake from your diet directly as body fat
2) It decreases your energy levels - meaning that finding the motivation to work out or eat healthy becomes a huge challenge.
3) It increases cravings and hunger - meaning that sticking to a healthy diet becomes a daily battle.

7) Poor Energy Levels

On my Facebook page, I often make posts about how PCOS can utterly empty your energy levels. The tough part about PCOS and your energy levels is there’s no real medical diagnoses for having no energy so it’s often an overlooked symptom of PCOS.

It’s also hard because it’s not like we walk around with a sign above our heads alerting everyone else to our energy levels like in a playstation game, so most people just don’t understand how tired or exhausted you may be.

There are a few key causes of how PCOS saps your energy.

1) Insulin Resistance - In women with IR, the cell doors are essentially closed, this means the cells that need those nutrients and energy to function are now starving. These cells now send signals to your brain to reduce energy expenditure - making you feel tired. Even if you’re eating a good amount of food, with IR the cells may not be getting the energy from your diet.

2) Hormonal Imbalances - The hormone estrogen plays a crucial role in energy levels. Estrogen is primarily produced in the first phase of the menstrual cycle as your follicles start to mature for ovulation. PCOS can cause irregular or missing menstrual cycles leading to low estrogen levels. Low estrogen will negatively impact your energy levels. Also, low estrogen is associated with anxiety, poor mood, difficulty concentrating, weight gain, and disrupted sleep.

3) Sleep Issues - PCOS is associated with insomnia and sleep apnea. Researchers are still trying to identify the exact causes but, once again, your sleep/wake cycle is impacted by your hormonal balance. Hormones such as cortisol, often chronically elevated in PCOS can have a detrimental effect on both the quality and quantity of sleep you get.

8) Dark Skin Patches, Or Acanthosis Nigricans

Women with PCOS can often experience patches of dark, brown, velvety skin. These skin patches are properly known as acanthosis nigricans, and can occur anywhere on the body. The cause of these patches is insulin resistance. Because these patches are visible, they are often the first sign that there is something wrong hormonally.

The most common parts of your body that acanthosis nigricans occur is:
- Armpit
- Groin
- Knees
- Elbows
- Knuckles
- Lips

Numerous studies have linked hyperinsulinemia (high insulin levels) with acanthosis nigricans. They also found a relationship between these dark patches and high androgen levels in women with PCOS.

In fact, acanthosis nigricans is more common in obese hyperandrogenic women with PCOS. What does this all mean? The presence of these dark, velvety skin patches is a sign of abnormal blood sugar tolerance in women who have PCOS. And being overweight puts you at a greater risk.

9) Sleep Issues

As I mentioned before, we still don’t truly understand exactly how and why PCOS can have you counting sheep all night when you should be getting quality shut eye. In terms of trying to fall asleep, well your body clock is reliant upon certain hormones being in a healthy balance.

For example, your stress hormone is high in the mornings, helping to wake you up but, low in the evenings to ensure you can fall asleep. We know many women with PCOS have chronically elevated levels of cortisol, meaning it can be extremely challenging trying to fall asleep without issue.

Women with PCOS also report higher instances of sleep disturbances throughout the night. Since there are stages of sleep, five in total, if you’re constantly waking up throughout the night your body isn’t getting the quality sleep you need.

For example, ‘deep sleep’ occurs in stage 3 of non-REM sleep. Of all of the sleep stages, stage 3 provides the most restorative sleep of all the sleep stages. This is why if you take a short nap during the day, you’re still able to fall asleep at night. But if you take a nap long enough to fall into deep sleep, you have more difficulty falling asleep at night because you reduce your need for sleep.

During deep sleep, the hormone human growth hormone (HGH) is released and restores your body and muscles from the stresses of the day. Your immune system also restores itself. So, if PCOS is causing you to constantly toss and turn all night - you may wake up in the morning and feel like you haven’t slept (rested) a wink.