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PCO, OCP that is a palindrome, something that's the same when you read it forwards and backwards, but it also refers to a common hormonal problem in women, and something used for management. This is not a quiz game, but this is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

PCO, polycystic ovaries and polycystic ovary syndrome is a hormonal condition in women of reproductive age. It's not a disease, but a syndrome, meaning a constellation of symptoms and findings without a single common cause. The symptoms and the findings that define PCOS include irregular periods and evidence of increased androgens or male hormones. Some definitions include having multiple small cysts on the ovaries that can be seen on ultrasound. However, not all women all over the world have access to an ultrasound to look at their ovaries, so many experts just use irregular periods and evidence of androgen excess. Also, young women who have lots of eggs, have lots of follicles. So, on ultrasound, they look like they've PCOS, but they don't. So the ultrasound part is kind of controversial.

Irregular periods mean that menstruation comes more than 35 days apart, and not on a schedule. Now, some women feel that their cycles are irregular, if some months they have periods on the 15th of the month and some months on the 17th, but PCOS means that the cycles are much more irregular and often without ovulation. If women who have PCOS usually don't ovulate, they don't make the hormone progesterone, which is made by the ovulation cyst, and is important for keeping the uterus healthy each month. So having regular periods makes the uterus healthy, and having irregular periods can lead to unpleasant or dangerous bleeding and a not very healthy uterus.

The excess androgens part of PCOS means that women have more than normal levels of hormones made by the ovary that are like testosterone. Now, all women make male hormones. In fact, the female hormone estrogen is made out of male hormones. However, women with PCOS have many small egg follicles that are stuck in development that makes male hormones. That's the polycystic part of polycystic ovaries. These little follicles usually do not ovulate. They don't make the estrogen at the level of an ovulating follicle, and they don't make progesterone to keep the uterus lining healthy and that causes irregular periods.

So what are the main symptoms of PCOS? Well, irregular periods and excess hair growth on the face and other parts of the body. If a woman with PCO is trying to get pregnant and doesn't ovulate, she may be infertile. Many women with PCOS have gained weight, and this complicates the problem of irregular periods and extra male hormones. Some women have insulin resistance and may be prediabetic, partly related to the PCO part and partly related to obesity.

Now, PCOS is very common, as many as 1 in 20 to 1 in 10 women have this syndrome. It was probably less common in years past when women were much less likely to be obese, and not all women experienced PCO to the same degree. Some women have slightly irregular periods with only minimal signs of excess male hormones, and some women have extremely irregular periods and very significant hirsutism or excess body hair.

Okay, that's the PCO part. What about the OCP part? Oral contraceptive pills have estrogen and progestin in them. The way OCPs work for contraception is to block the development of follicles, so ovulation doesn't happen and they control the uterus lining, so periods are regular and light. The way OCPs work by suppressing the development of little follicles, those little cysts that can make male hormones, make them useful in controlling symptoms of PCO. Also, women with PCO have estrogen but lower amounts and the higher estrogens in the OCPs can help counteract the effects of male hormones. The progestin in the OCPs help control the lining of the uterus, so women can have regular periods. There you go.

Now, clearly OCPs do not cure PCO, but they are very useful in the control of symptoms. There's even some evidence that women who are taking OCPs for the PCOS and then choose to try to get pregnant, may actually be more likely to ovulate the first several months after stopping OCPs. Not all women who have PCO are good candidates for OCPs. Some women with PCO who are obese and have high blood pressure, which may be a contraindication to OCPs. Some women don't like the way they feel on OCPs, although many women with PCO say they feel better on OCPs.

Are you guys getting tired of the PCO or OCP palindrome? Well, hang in there. We're almost done. Some women may have other contraindications to OCPs, including a history of blood clots or migraine headache. And of course, some women want to get pregnant. For women who are overweight with PCO, their first effort might be diet and exercise with the focus on weight loss. Women with PCO who lose as little as 10% of their body weight are more likely to ovulate and to have regular periods. Then, of course, they may choose OCPs for birth control. For some young women, a diet low in refined carbohydrates, high in vitamins and minerals and good nutrition, and regular exercise may make them feel the best. However, for some women, and many women, diet and exercise do not work to control their symptoms and OCPs may be the best option.

There are many kinds of OCPs, but they all work mostly the same way. The combination pills with estrogen and progestin work the way we just talked about. The lowest dose pill that does the job would be the first choice. The OCPs are different in the kind of progestin in the pill, and some women feel better on one pill than another. They all work to control periods and lower male hormone effects. So, because PCO is so common, most primary care providers, which include internists, family physicians, pediatricians who see teenagers, and OB/GYNS are familiar with the signs and symptoms and routine treatments. However, there are other options in treatments for symptoms other than OCPs and weight loss and exercise and diet. If a woman with PCOS is struggling to understand her condition, is not getting help with symptoms, or is struggling to get pregnant, she may want to see a specialist in PCOS such as a reproductive endocrinologist.

PCOS is complicated in all of the 7 domains of women's health -- physical, emotional, social, environmental, intellectual, financial, and spiritual. Having irregular periods, being infertile, having the body that you don't think is really you, all those things are affected. If you or someone you know is struggling, we can help. And thanks for joining us on The Scope.

My patients tell me that they've had an ovarian cyst. "What kind?" I ask. "I don't remember," is the common answer. Well, that's not a helpful answer.

Ovarian cyst comes in two flavors, functional cysts and nonfunctional cysts. Functional cysts are usually the good kind. They arise from the function of the ovary. A woman who ovulates makes a cyst about one inch in diameter every month. And there are a lot of smaller cysts every month that go along for the ride. These functional cysts come in two types. Follicular cysts that have the eggs and corpus luteum cysts that the follicular cyst turns into after ovulation.

Now the Follicular cyst is filled with clear fluid, doesn't have much of a blood supply, and occasionally can get pretty big, as big as four inches. Getting that big isn't common, but it happens. And unless there's a lot of pain with this big cyst, the important thing is to leave it alone. These cysts go away after a few weeks. How do you know if you have one? Well, every woman with functional cysts has these, and they usually don't know about them unless they're getting an ultrasound for some reason.

We watch these cysts grow with great interest and hope in infertility therapy and in vitro fertilization. Sometimes a woman can learn she has one because it becomes bigger and causes pain. Follicular cysts can look a certain way on ultrasound, clear fluid, with a very thin cyst wall. So we know for pretty sure that these are good cysts, and we try to wait and let them go away.

After ovulation, the follicular cyst becomes a corpus luteum cyst. This is a progesterone factory whose job it is to make the hormones to prepare the uterus for pregnancy. If no pregnancy occurs with the ovulation, then these cysts go away in about two weeks. These cysts are very active making hormones, and they have a rich blood supply. If they get bumped, and you can figure out ways that they could get bumped, they can bleed and grow rapidly with blood and can hurt.

Women who have a corpus luteum cyst that bleeds a lot can come to the doctor or the emergency room and an ultrasound can usually make the diagnosis because they look like a cyst with new blood in it. We try not to operate and let the cyst go away on its own, which may take a month or so. Sometimes there's so much bleeding into the abdomen that it requires surgery, but we try not to operate and leave scars on the ovary if possible. So when a woman can tell me that she had a functional cyst or a corpus luteum cyst that required surgery or a follow-up, I know I don't have to worry because these are the good cysts.

Now, the bad cysts. There are nonfunctional cysts or neoplastic new tissue cysts new tissue cysts. Any of the tissues in the ovary can grow to make a cyst and some of these cysts can get big, really, really, really big. The biggest neoplastic cyst in recorded history was 328 pounds. That is really big. These cysts come in different types, depending on the kind of cells that made these cysts. Serous cysts, mucinous cysts, dermoid cysts, I could go on.

We usually operate to remove these cysts when they get bigger than two inches because they can grow and it's much easier to remove a cyst when it's two inches than when it's 20 inches or bigger, bigger, bigger. We cannot tell exactly what kind of cyst it is some of the time just by looking at an ultrasound, but we do know what it is when the pathologist looks at it. Some cysts are made out of egg tissue make hair and teeth and other kinds of tissues, and they look a certain way on ultrasound. But usually, we give them to the pathologist and let them figure it out. Why should you know what kind of cyst you had removed? Because some cysts tend to predict that you'll get another one.

Now, for the ugly. Some nonfunctional cysts are ovarian cancer. This is another reason that we remove nonfunctional cysts when they grow and look different on ultrasound than functional cysts. Ovarian cancer is not terribly common. About 10 per 100,000 women per year or a little more than 1% risk in a woman's lifetime.

Ovarian cancer has no symptoms when it's very small so it can be hard to catch early. When a cancerous ovarian cyst gets bigger, it can cause pain, and pressure and a feeling of abdominal fullness because we cannot always tell which cysts or cancerous on ultrasound. Although cancer cysts do tend to look quite different from functional cysts, we tend to want to remove cysts when they grow, and especially if we find them in women who are post-menopausal and shouldn't be making cysts.

So if you've had surgery or medical care for an ovarian cyst, you should keep a record of what kind of cyst it was. Get a copy of the report from your doctor and keep it in your medical records. Ovarian cysts come in different types, and we have different concerns, and different follow-up, for women with some cysts. In fact, any woman who has had surgery on her reproductive organs should have a copy of her operative report and pathology in her permanent medical records.

Maybe someday, we'll have a universal electronic medical record and all of it will be there for your doctor to help you. But until then, keep your own copies on file and thanks for joining us on The Scope.

updated: July 9, 2020
originally published: August 11, 2016

Dr. Jones: "I have irregular periods, and I'm overweight. Do I have PCOS? I looked it up on the web." This is a question I hear all the time. What is PCOS, and how do you know if you have this condition? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and we're talking about the most common endocrine problem in women today on The Scope.

Announcer: Covering all aspects of women's health, this is The 7 Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: PCOS, I hear some people say, "P-COS," but in fact, those of us in the know just say, "P-C-O-S" is polycystic ovarian syndrome. The "poly-" part is "many," the "-cystic" part is little fluid-filled pockets, the "ovary" part is self-explanatory, and the "syndrome" part is that it's a condition with several symptoms and it's not caused by any one thing. It's not a specific disease.

So the many cysts are very small, little egg cysts called follicles in the ovary, stuck, in that they are less than a half inch, and they are ordinarily much smaller than a normal follicle. It makes an egg. They don't grow big and hatch an egg every month, and they don't go away every month. They eventually shrink, but new ones take their place.

Because they don't grow big to about an inch and hatch out of the egg every month, women with PCOS don't have regular periods. Their periods are more than 35 days apart, and they're not predictable. This is one of the symptoms of PCOS. Now, there are many different conditions and diseases that can make irregular periods. Women at the beginning of their reproductive life and at the end of reproductive life are almost always irregular for a while.

The other symptom, which may be subtle comes from the fact that all these little egg follicles in the ovary make male hormones, and this is normal. When you have a lot of them, though, you have increased male hormones. Until a follicle gets big enough to make estrogen and ovulate, they make male hormones, so the other symptom that goes with PCOS is an excess of male hormones. Now, this isn't a huge excess, nowhere near the level that men have, but enough that some women may have acne or hair growth on their face or abdomen, coarse hair, not the little fine hairs that all women have.

So you said you were overweight and had irregular periods. Although many women with PCOS are overweight and being overweight does complicate PCOS, it isn't necessary for the syndrome. What is necessary for the syndrome of PCOS has been debated furiously on both sides of the Atlantic for more than 50 years.

Europeans prefer that the diagnosis be made by two of the following three findings. Irregular periods, evidence of excess of androgens or male hormones, and multiple little cysts on the ovary on ultrasound. Well, these criteria would be seen in every adolescent with irregular periods and acne, which most 13-year-olds have. Americans like just two criteria, but you have to have both, irregular periods and evidence of extra male hormones.

If you Google PCOS, and you'll find that this syndrome is found in 5% to 10% of women in reproductive age, PCOS isn't a syndrome of little girls or post-menopausal women. But 1 in 10 to 1 in 20 young women will have this. It is very common. Also, if you make the mistake of Googling PCOS, you will scare yourself by the claims of PCOS women that they will be infertile, obese, hairy, diabetic, and die early from heart disease.

We know that women with PCOS can have a hard time getting pregnant, but most of them will if they seek medical care, and many of them will, even if they don't. Those sneaky little eggs do ovulate on occasion. Weight management is particularly important for women with PCOS, as many do have an increased risk of Type 2 diabetes, but many don't get diabetes. Women with PCOS, who are obese, have more difficulty getting pregnant and staying pregnant than those of normal weight or those obese women who don't have PCOS.

And the claims of increased coronary heart disease have not really panned out, so I wouldn't worry about that, except that all women should worry about that.

Okay, so how do you know if you have PCOS? If you have irregular periods and you aren't a teen or breastfeeding or using hormonal contraception or close to menopause, you should see your doctor. And if you have unwanted acne and facial hair, you probably want to see your doctor. If you have both, you may have PCOS.

And there are many ways to manage the symptoms or help you get pregnant if you want to. There are a few rare conditions that look like PCOS, problems with the adrenaline glands or tumors that make male hormones, but these are very, very rare and easy to rule out.

PCOS is common, and the signs and symptoms can make a woman worried and unhappy, but there are lots of things we can do. We don't have a cure, but we have some very good workarounds. If your primary care doctor or your OB/GYN can't help you get your symptoms under control, there are specialists called reproductive endocrinologists who can help you out.

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