ASK: "Does Birth Control Alleviate PCOS?"

Recently we received a query from a PCOSA Today reader via readersbuzz.com asking if any form of permanent birth control could help alleviate PCOS. This is an important question that doctors who work with PCOS hear frequently. Many patients who are prescribed the birth control pill to help with PCOS erroneously believe that hormonal contraceptives can dramatically improve or reverse all of their PCOS symptoms.

To understand the situation properly, we need to delve into the patho-physiology of PCOS: that is, the underlying physical mechanisms that cause and perpetuate the disease in a woman's body.

First, please note that the medical establishment does not have definitive answers about what causes PCOS in every person who has it. We have theories which seem to hold true overall, but not everyone with PCOS will have the same hormonal profile or the same symptoms.

The general consensus with PCOS is that the condition is caused by insulin resistance. With insulin resistance, the body's cells, which are normally sensitive to insulin's effects, stop responding to this hormone. A vicious cycle begins when the body senses that glucose is low in the cells and therefore the pancreas is instructed to release even more insulin in an attempt to rectify the glucose levels. This results in a worsening of insulin resistance, as the cells are bombarded with more and more insulin.

In some women with PCOS, their blood sugar will rise, but many women have normal glucose levels while their fasting or post-prandial (after eating) insulin levels are high, reflecting that insulin has to work harder and harder to maintain normal blood sugar levels. Serum insulin levels are a much better measure of insulin resistance than blood glucose levels. The imbalance of insulin and glucose is why one of the primary long-term concerns of women with PCOS is the development of diabetes and heart disease.

Elevated insulin causes an imbalance of the sex hormones (for example, estrogen, progesterone, and testosterone) in women with PCOS. For unknown reasons, the ovaries of women with PCOS may be excessively sensitive to insulin, resulting in the ovaries producing higher levels of the male hormones (androgens) testosterone and androstenedione.

Also, too much insulin reduces a substance called Sex Hormone Binding Globulin (SHBG) thereby allowing more testosterone to be unbound and therefore more "active." This contributes to the masculinizing symptoms that characterize PCOS, like unwanted hair growth and acne.

Thus, PCOS is not simply a hormone imbalance involving estrogen, progesterone, testosterone, and DHEA (Dehydroepiandrosterone, another natural hormone). The disorder runs deeper than that, involving insulin and glucose (and probably cortisol) as well.

Because having PCOS may often affect fertility, it is thought by some to be simply a reproductive issue. This is not true. PCOS is a condition of the endocrine system, a group of glands that work together and secrete different kinds of hormones that regulate the body.

This is why using hormonal birth control options like the birth control pill or patch will not cure PCOS nor will they alleviate symptoms altogether.

Hormonal contraceptives do not address the underlying insulin resistance which has contributed to the sex hormone imbalance in the first place. They may improve some PCOS symptoms temporarily while the woman continues to use the birth control, but contraceptives do not cure PCOS.

Similarly, hysterectomy will also not cure PCOS. Some women with PCOS are under the impression that removing the uterus and ovaries will eradicate their PCOS but this is not the case, for the reasons mentioned above. Hysterectomy does nothing to change the underlying insulin resistance.

Furthermore, PCOS is a syndrome that involves multiple organs and tissues: ovaries, adrenal glands, pancreas, and fat stores. Each of these sites produces hormones that are part of this complicated condition . For instance, since estrogen, progesterone, and testosterone are produced in both the ovaries and the adrenal glands, and fat cells can produce estrogen, removing the ovaries in a hysterectomy does not preclude the body from making any more sex hormones! Therefore while removing the uterus and ovaries may remove some symptoms like irregular menses, heavy menses, and ovarian cysts, hysterectomy may not actually have a profound effect on the hormonal milieu that creates and exacerbates PCOS.

Unfortunately there is no easy answer to improving PCOS. The good news is that insulin resistance is a highly modifiable condition, using nutrition and exercise and in some cases adding in nutrients and herbs. The positive effect of exercise and selective food intake cannot be underestimated in reversing insulin resistance, and therefore in vastly improving a woman's experience of PCOS.

Dr. Sari Cohen