Are high [progesterone](https://nabtahealth.com/glossary/progesterone/) levels causing concern? Understanding the impact of elevated [progesterone](https://nabtahealth.com/glossary/progesterone/) is crucial for maintaining hormonal balance and overall health. [Progesterone](https://nabtahealth.com/glossary/progesterone/) plays a vital part in the menstrual cycle and pregnancy, but when levels rise unreasonably, it can [lead](https://nabtahealth.com/glossary/lead/) to different indications and well-being challenges. This article dives into the signs, causes, and suggestions of tall [progesterone](https://nabtahealth.com/glossary/progesterone/) levels, advertising clear experiences and viable counsel to address this common hormonal issue. Whether experiencing symptoms or seeking preventative measures, powering yourself with knowledge can guide you toward optimal hormonal wellness. You’re not alone in this journey; we’re here to support you. * High [progesterone](https://nabtahealth.com/glossary/progesterone/) symptoms include fatigue, bloating, breast tenderness and [vaginal dryness](https://nabtahealth.com/articles/5-reasons-why-you-may-be-experiencing-vaginal-dryness). * [Progesterone](https://nabtahealth.com/glossary/progesterone/) naturally increases when you become pregnant. * Maintaining [progesterone](https://nabtahealth.com/glossary/progesterone/) at a ‘normal’ level has health benefits, for example it can help boost your mood. * Low [progesterone](https://nabtahealth.com/glossary/progesterone/) levels is one of the characteristics of [anovulation](https://nabtahealth.com/glossary/anovulation/) (lack of [ovulation](https://nabtahealth.com/glossary/ovulation/)), which is a symptom of [PCOS](https://nabtahealth.com/glossary/pcos/). * If your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are too high and you are not pregnant, some causes can include ovarian cysts, congenital [adrenal hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/) and ovarian cancer. #### I have high [progesterone](https://nabtahealth.com/glossary/progesterone/) symptoms. Am I pregnant? Measuring your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels is a good way of confirming whether or not [ovulation](https://nabtahealth.com/glossary/ovulation/) has taken place. However, high or low [progesterone](https://nabtahealth.com/glossary/progesterone/) can be associated with other conditions. #### My [progesterone](https://nabtahealth.com/glossary/progesterone/) is low… One of the [main symptoms of](../what-is-pcos) [PCOS](https://nabtahealth.com/glossary/pcos/) is [anovulation](https://nabtahealth.com/glossary/anovulation/) (failure to ovulate), characterized by [low](../what-happens-if-my-progesterone-levels-are-too-low) [progesterone](https://nabtahealth.com/glossary/progesterone/). To diagnose [PCOS](https://nabtahealth.com/glossary/pcos/), most guidelines state that two out of the three main symptoms ([anovulation](https://nabtahealth.com/glossary/anovulation/), [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/), and polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/)) should be present. It is possible to have [](https://nabtahealth.com/i-have-regular-periods-could-i-still-have-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/) and also have periods that are regular. A lack of [progesterone](https://nabtahealth.com/glossary/progesterone/), in addition to serving as a marker of [anovulation](https://nabtahealth.com/glossary/anovulation/), also contributes to higher circulating levels of [testosterone](https://nabtahealth.com/glossary/testosterone/), contributing to another of the major symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/), [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). [Boosting low](https://nabtahealth.com/alternatives-to-progesterone-supplements-for-managing-pcos/) [progesterone](https://nabtahealth.com/glossary/progesterone/) levels has health benefits (preventing over-exposure of the [uterus](https://nabtahealth.com/glossary/uterus/) to [oestrogen](https://nabtahealth.com/glossary/oestrogen/)) and will serve as a natural mood enhancer. If you are concerned that your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are too high, find out quickly, discreetly, and conveniently by taking an [at-home women’s health fertility test](https://nabtahealth.com/product/womens-fertility-test/). The results will allow you to make informed decisions about your next steps. #### But, what about if [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are higher than normal? First, it is worth considering what is ‘normal? [Progesterone](https://nabtahealth.com/glossary/progesterone/) levels in the serum naturally fluctuate, not just throughout the menstrual cycle, when they can feasibly go from 0 to 20ng/ml, but also on an hour-by-hour basis. This makes defining ‘normal’ challenging. [Progesterone](https://nabtahealth.com/glossary/progesterone/) is not present at all during the follicular phase of the cycle and will only start to rise after [ovulation](https://nabtahealth.com/glossary/ovulation/), reaching a peak 7-5 days before menstruation starts. This peak is often around 8ng/ml, but can be as high as 20ng/ml. Without fertilization, [progesterone](https://nabtahealth.com/glossary/progesterone/) levels fall swiftly back to zero for the start of the next menstrual cycle. If fertilization does occur, Chart will remain high as the hormone helps to prepare the body for pregnancy. Symptoms of high [progesterone](https://nabtahealth.com/glossary/progesterone/) include fatigue, bloating, moodiness, breast tenderness, and vaginal dryness, these can all be very [](../subtle-signs-of-pregnancy)[early signs of pregnancy](../subtle-signs-of-pregnancy). It is not abnormal for [progesterone](https://nabtahealth.com/glossary/progesterone/) levels to reach 85-90ng/ml during the first and second trimester, dropping to approximately 45ng/ml in the third trimester as the body prepares for birth. Multiple births (twins or triplets) usually give rise to higher than average levels. So, if your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels seem high, the first thing to consider is whether or not you might be pregnant. #### I’m not pregnant; what else causes high [progesterone](https://nabtahealth.com/glossary/progesterone/) levels? If pregnancy is not the reason for higher than normal [progesterone](https://nabtahealth.com/glossary/progesterone/) levels, there are a few other conditions that might [lead](https://nabtahealth.com/glossary/lead/) to high levels of the hormone: * [Ovarian cysts](../are-ovarian-cysts-the-same-thing-as-pcos). Some ovarian cysts occur alongside an excess of [progesterone](https://nabtahealth.com/glossary/progesterone/), however, which causes which is unclear. Ovarian cysts are usually [benign](https://nabtahealth.com/glossary/benign/), often form as part of normal menstruation and, unless they rupture, will generally cause few side effects. (If you have [ovarian cysts you do not necessarily have](https://nabtahealth.com/are-ovarian-cysts-the-same-thing-as-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/).) * Congenital [adrenal hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/). A group of rare inherited conditions that affect the production of hormones, including [androgens](https://nabtahealth.com/glossary/androgen/), by the adrenal glands. * [Ovarian cancer](https://nabtahealth.com/ovarian-cancer-symptoms/) and adrenal cancer. These are both rare and will usually be accompanied by other symptoms such as pain and bleeding. To conclude, if you have high levels of [progesterone](https://nabtahealth.com/glossary/progesterone/), the first thing to do is re-test your chart, taking into account the tendency for fluctuations in readings. Also, bear in mind that having healthy levels of [progesterone](https://nabtahealth.com/glossary/progesterone/) is generally a good thing; it makes periods lighter, reduces anxiety, is anti-inflammatory, and improves the appearance of the skin and hair. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#334a525f5f52735d525147525b56525f475b1d505c5e) if you have any questions about this article or any aspect of women’s health. We’re here for you. #### **Sources:** Briden, L. “Roadmap to [Progesterone](https://nabtahealth.com/glossary/progesterone/).” _Lara Briden – The Period Revolutionary_, 19 Jan. 2014, [www.larabriden.com/road-map-to-](http://www.larabriden.com/road-map-to-progesterone/)[progesterone](https://nabtahealth.com/glossary/progesterone/)/. Holm, G. “Serum [Progesterone](https://nabtahealth.com/glossary/progesterone/) Test: Purpose, Results, and Risks.” _Healthline_, [www.healthline.com/health/serum-](http://www.healthline.com/health/serum-progesterone)[progesterone](https://nabtahealth.com/glossary/progesterone/). Medically reviewed by University of Illinois-Chicago, College of Medicine on August 22, 2016. “[Progesterone](https://nabtahealth.com/glossary/progesterone/).” _Lab Tests Online_, AACC, [labtestsonline.org/tests/](http://labtestsonline.org/tests/progesterone)[progesterone](https://nabtahealth.com/glossary/progesterone/). This article was last modified on December 28, 2018.
Polycystic ovary syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is a common hormonal disorder that affects women of reproductive age. It is caused by a hormonal imbalance in the body and can [lead](https://nabtahealth.com/glossary/lead/) to a number of symptoms, including irregular menstrual periods, excess hair growth, acne, and weight gain. While urinary and bowel issues are not typically considered common symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/), they can occur in some individuals with the condition. The most common urinary symptom associated with [PCOS](https://nabtahealth.com/glossary/pcos/) is urinary tract infections (UTIs), which can cause symptoms such as frequent or urgent urination, [pain or burning during urination](https://nabtahealth.com/articles/can-pcos-cause-urinary-and-bowel-issues/), and cloudy or bloody urine. These symptoms can be treated with antibiotics. * [PCOS](https://nabtahealth.com/glossary/pcos/) cause urinary and bowel issues even when women have non-classic [PCOS](https://nabtahealth.com/glossary/pcos/). * This is because the cysts may press against the bladder and rectum (bowel). * Cysts can be removed under general anaesthetic. * [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms can be relieved through changing your lifestyle. #### Classic and Non-Classic [PCOS](https://nabtahealth.com/glossary/pcos/) Despite its name, polycystic ovary syndrome [](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/)[does not require the presence of polycystic](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/) [](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/)[ovaries](https://nabtahealth.com/glossary/ovaries/). In fact, when present together, excess of male hormones ([hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/)) and lack of [ovulation](https://nabtahealth.com/glossary/ovulation/) ([anovulation](https://nabtahealth.com/glossary/anovulation/)) comprise the [classic form of](https://nabtahealth.com/what-is-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/), which is more common and generally associated with more severe side effects than the non-classic form. Women who have non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) can have [polycystic](https://en.wikipedia.org/wiki/Polycystic_ovary_syndrome) [ovaries](https://nabtahealth.com/glossary/ovaries/) with regular menstrual cycles and [](https://nabtahealth.com/is-hyperandrogenism-a-symptom-of-pcos/)[hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (non-classic ovulatory [PCOS](https://nabtahealth.com/glossary/pcos/)). Or they can have normal [androgens](https://nabtahealth.com/glossary/androgen/) but experience chronic [anovulation](https://nabtahealth.com/glossary/anovulation/) (non-classic mild/normoandrogenic [PCOS](https://nabtahealth.com/glossary/pcos/)). #### [PCOS](https://nabtahealth.com/glossary/pcos/) Can Cause Urinary and Bowel Issues Although non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) is typically milder, those women who have extensive ovarian cysts may experience pain in the pelvic region where the cysts press against the bladder and rectum. Associated symptoms include nausea, urinary conditions, and [constipation](https://nabtahealth.com/glossary/constipation/). Depending on the severity of the symptoms, treatment options range from over-the-counter pain relief medication to cyst removal under general anaesthetic. Ultrasound investigation will be used to establish how invasive the cysts are. In addition to the pain and pressure caused by the presence of cysts in the abdominal region, many women with [PCOS](https://nabtahealth.com/glossary/pcos/) experience symptoms that are usually associated with diabetes. This is probably because a large proportion of women with the condition are insulin resistant. Symptoms such as sugar cravings, frequent urination, blurred vision, delayed healing, and a tingling sensation have all been reported. To date, the most effective way of relieving the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/) is through the implementation of [lifestyle changes](https://nabtahealth.com/is-it-possible-to-reverse-pcos/), such as weight loss. What are the common urinary and bowel symptoms associated with [PCOS](https://nabtahealth.com/glossary/pcos/)? -------------------------------------------------------------------------------------------------------------- * Polycystic ovary syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is a common hormonal disorder that affects women of reproductive age. * It is caused by a hormonal imbalance in the body and can [lead](https://nabtahealth.com/glossary/lead/) to a number of symptoms, including irregular menstrual periods, excess hair growth, acne, and weight gain. * While urinary and bowel issues are not typically considered common symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/), they can occur in some individuals with the condition. * The most common urinary symptom associated with [PCOS](https://nabtahealth.com/glossary/pcos/) is urinary tract infections (UTIs), which can cause symptoms such as frequent or urgent urination, pain or burning during urination, and cloudy or bloody urine. * Another urinary issue that can occur with [PCOS](https://nabtahealth.com/glossary/pcos/) is incontinence, or the inability to control the release of urine from the bladder. * [Constipation](https://nabtahealth.com/glossary/constipation/) is a common symptom of [PCOS](https://nabtahealth.com/glossary/pcos/). This can be caused by hormonal imbalances and changes in the levels of insulin and other hormones in the body. * It’s important to talk to a doctor if you have [PCOS](https://nabtahealth.com/glossary/pcos/) and are experiencing any symptoms related to your urinary or bowel health. They can help diagnose and treat any underlying issues and provide you with the care and support you need to manage your condition. To read more about factors that are associated with [PCOS](https://nabtahealth.com/glossary/pcos/) click [here](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/) and consider Nabta’s [](https://nabtahealth.com/product/pcos-test/)[PCOS](https://nabtahealth.com/glossary/pcos/) Test to understand more. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#81f8e0edede0c1efe0e3f5e0e9e4e0edf5e9afe2eeec) if you have any questions about this article or any aspect of women’s health. We’re here for you. FAQ’s On [PCOS](https://nabtahealth.com/glossary/pcos/) Cause Urinary and Bowel Issues? --------------------------------------------------------------------------------------- ### Can [PCOS](https://nabtahealth.com/glossary/pcos/) Cause Blood In Urine Yes, Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) can indirectly cause blood in urine due to associated conditions like urinary tract infections (UTIs) or kidney issues. It’s important to consult a healthcare provider for an accurate diagnosis and appropriate treatment. ### [PCOS](https://nabtahealth.com/glossary/pcos/) Urine Color [PCOS](https://nabtahealth.com/glossary/pcos/) does not usually change urine color directly. However, related conditions such as UTIs or dehydration can cause urine to appear darker, cloudy, or bloody. Consult a healthcare provider if you notice unusual changes in urine color. Does [PCOS](https://nabtahealth.com/glossary/pcos/) Cause You To Pee a Lot -------------------------------------------------------------------------- Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can cause you to pee a lot due to related conditions like [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or diabetes, which can increase thirst and urination. It’s essential to consult a healthcare provider for proper diagnosis and management. ### Can [PCOS](https://nabtahealth.com/glossary/pcos/) Cause UTI Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can increase the risk of urinary tract infections (UTIs) due to hormonal imbalances and [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). It’s important to consult a healthcare provider for proper diagnosis and treatment. ### [PCOS](https://nabtahealth.com/glossary/pcos/) Peeing a Lot Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can cause frequent urination due to associated conditions like [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or diabetes, which can [lead](https://nabtahealth.com/glossary/lead/) to increased thirst and urination. Consult a healthcare provider for proper diagnosis and management. #### **Sources:** El Hayak, S, et al. “Poly Cystic Ovarian Syndrome: An Updated Overview.” _Frontiers in Physiology_, vol. 7, 5 Apr. 2016, p. 124., doi:10.3389/fphys.2016.00124. Norman, R J, et al. “The Role of Lifestyle Modification in Polycystic Ovary Syndrome.” _Trends in Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/)_, vol. 13, no. 6, Aug. 2002, pp. 251–257. Patel, S. “Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)), an Inflammatory, Systemic, Lifestyle Endocrinopathy.” _The Journal of Steroid Biochemistry and Molecular Biology_, vol. 182, Sept. 2018, pp. 27–36., doi:10.1016/j.jsbmb.2018.04.008.
* [PCOS](https://nabtahealth.com/glossary/pcos/) is sometimes treated with metformin, a drug for [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). * 60-70% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) are insulin resistant which is why metformin may be prescribed. * Clinical studies exploring metformin and [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms have been small and inconsistent, but there is some evidence metformin increases [ovulation](https://nabtahealth.com/glossary/ovulation/) rate in women with [PCOS](https://nabtahealth.com/glossary/pcos/) when compared to treatment with a placebo. * Other studies have found that there is no consistent evidence that metformin improves the signs of hyperandrogegism (such as hairiness from excess male hormones). * However, metformin should not be completely discounted as an option for the management of [PCOS](https://nabtahealth.com/glossary/pcos/) [Metformin](https://nabtahealth.com/what-is-metformin/) is the first line treatment approach for type 2 diabetes mellitus (T2DM). It works by improving the way in which the body responds to insulin, preventing blood sugar levels from getting too high. Metformin is not licensed for the treatment of [](https://nabtahealth.com/what-is-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/), but as many women with the condition are [insulin resistant](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/), it is often prescribed ‘off label’ to help manage the symptoms. This article aims to address some questions regarding the use of metformin in the management of [PCOS](https://nabtahealth.com/glossary/pcos/). Is there justification in its use? Can it help to improve the symptoms of the condition, or are there alternative options that will be more effective? Will there ever be a time when metformin is prescribed as standard for all women with [PCOS](https://nabtahealth.com/glossary/pcos/) and to treat [PCOS](https://nabtahealth.com/glossary/pcos/) side effects? #### **Why metformin and [PCOS](https://nabtahealth.com/glossary/pcos/)?** Metformin is safe and cost effective, hence it’s widespread use in the management of T2DM. [Insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) is not one of the three diagnostic criteria used in defining [PCOS](https://nabtahealth.com/glossary/pcos/), however it is recognised as a common feature. In fact, 60-70% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) will be insulin resistant and it is thought that the higher than normal levels of insulin contribute to many of the phenotypic traits of the condition. Thus, it makes sense that treating the [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) might help to alleviate other [PCOS](https://nabtahealth.com/glossary/pcos/) side effects, for example regulating the menstrual cycle and improving signs of unwanted hair growth and acne. #### **What does the science say about [PCOS](https://nabtahealth.com/glossary/pcos/) and metformin?** Unfortunately metformin has not turned out to be the wonder drug that some anticipated. The clinical studies to date have largely been small in sample size and results have been inconsistent. In 2017, the American Society for Reproductive Medicine published guidelines on the use of metformin for the treatment of [infertility](https://nabtahealth.com/glossary/infertility/) in women with [PCOS](https://nabtahealth.com/glossary/pcos/). They based these guidelines on the results of a comprehensive literature review. The main conclusions reached were: * There is some evidence that metformin increases [ovulation](https://nabtahealth.com/glossary/ovulation/) rate in women with [PCOS](https://nabtahealth.com/glossary/pcos/) when compared to treatment with a placebo. **However:** * Clomiphene citrate is more effective at inducing [ovulation](https://nabtahealth.com/glossary/ovulation/) than metformin. * Metformin plus clomiphene citrate is more effective than metformin alone. * There is insufficient data on pregnancy and live birth rates following metformin treatment. Thus, the longer term overall reproductive benefit cannot currently be established. **Furthermore:** * There is insufficient evidence to recommend metformin as an option to [reduce the risk of](https://nabtahealth.com/pcos-and-pregnancy/) [miscarriage](https://nabtahealth.com/glossary/miscarriage/) in women with [PCOS](https://nabtahealth.com/glossary/pcos/). * Preliminary work suggesting that preventative treatment with metformin reduces the risk of [](https://nabtahealth.com/gestational-diabetes-8-things-you-should-know/)[gestational diabetes](https://nabtahealth.com/glossary/gestational-diabetes/) has not been replicated in newer studies. The final conclusion reached by the Society was that they would not recommend metformin as the first line treatment approach for [ovulation](https://nabtahealth.com/glossary/ovulation/) induction. Medications such as clomiphene citrate, known to be an [ovulation](https://nabtahealth.com/glossary/ovulation/) inducer, are generally more effective than metformin for women who are experiencing [PCOS](https://nabtahealth.com/glossary/pcos/)\-related fertility issues. In addition to these findings, other studies have found that there is no consistent evidence that metformin improves the signs of [](https://nabtahealth.com/masculine-hormones-in-women/)[hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). #### **The outlook for metformin as a [PCOS](https://nabtahealth.com/glossary/pcos/) treatment** Metformin should not be completely discounted as an option for the management of [PCOS](https://nabtahealth.com/glossary/pcos/). Whilst less effective than other options, metformin has been shown to restore [ovulation](https://nabtahealth.com/glossary/ovulation/) in some women with [PCOS](https://nabtahealth.com/glossary/pcos/). For women with [PCOS](https://nabtahealth.com/glossary/pcos/) clomiphene citrate is commonly used to induce [ovulation](https://nabtahealth.com/glossary/ovulation/), however, not all women respond to treatment with this drug. For the women that do not respond, it is possible that combination therapy with metformin may be more successful at inducing [ovulation](https://nabtahealth.com/glossary/ovulation/). However, the work on this to date is limited. There is a need for longer term studies on metformin, as most studies have only explored short course treatment approaches. [PCOS](https://nabtahealth.com/glossary/pcos/) varies considerably from woman to woman. The presenting symptoms differ in both type and severity, which is why [diagnosing it can be so challenging](https://nabtahealth.com/problems-with-traditional-diagnosis-of-pcos/). Women with [PCOS](https://nabtahealth.com/glossary/pcos/) are prone to other conditions such as obesity and [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/); they are also at greater risk of developing T2DM and [endometrial cancer](https://nabtahealth.com/a-guide-to-endometrial-cancer/). Whether metformin can be given prophylactically to reduce these risks remains unclear and once again highlights the need for longer-term studies with extensive follow-up periods. #### Will metformin be prescribed as standard to all women that receive a diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/)? Unlikely. A more valuable course of action would be for doctors to better understand the various [PCOS](https://nabtahealth.com/glossary/pcos/) phenotypes and thus, take a more individualised approach to treatment, deciding which of their patients could genuinely benefit from treatment with the drug. As a final note, the value of [lifestyle modifications](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) should not be understated. Adopting lifestyle changes and losing weight has proven to be, by far, the best approach for managing the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/). It is also the most effective way for women with [PCOS](https://nabtahealth.com/glossary/pcos/) to reduce their risk of developing T2DM. Medication should remain a contingency strategy for use in those who do respond adequately to lifestyle alterations. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#a0d9c1ccccc1e0cec1c2d4c1c8c5c1ccd4c88ec3cfcd) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Lashen, Hany. “Review: Role of Metformin in the Management of Polycystic Ovary Syndrome.” Therapeutic Advances in Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/), vol. 1, no. 3, June 2010, pp. 117–128., doi:10.1177/2042018810380215. * Practice Committee of the American Society for Reproductive Medicine (Penzias, Alan, et al.) “Role of Metformin for [Ovulation](https://nabtahealth.com/glossary/ovulation/) Induction in Infertile Patients with Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)): a Guideline.” Fertility and Sterility, vol. 108, no. 3, Sept. 2017, pp. 426–441., doi:10.1016/j.fertnstert.2017.06.026. * “Summary of Possible Benefits and Harms: Information for the Public: Polycystic Ovary Syndrome: Metformin in Women Not Planning Pregnancy: Advice.” NICE, Feb. 2013, [www.nice.org.uk/advice/esuom6/ifp/chapter/Summary-of-possible-benefits-and-harms](http://www.nice.org.uk/advice/esuom6/ifp/chapter/Summary-of-possible-benefits-and-harms). * “Treatment. Polycystic Ovary Syndrome .” NHS Choices, NHS, [www.nhs.uk/conditions/polycystic-ovary-syndrome-](http://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/treatment/)[pcos](https://nabtahealth.com/glossary/pcos/)/treatment/. * Yarandi, Razieh Bidhendi, et al. “Metformin Therapy before Conception versus throughout the Pregnancy and Risk of [Gestational Diabetes](https://nabtahealth.com/glossary/gestational-diabetes/) Mellitus in Women with Polycystic Ovary Syndrome: a Systemic Review, Meta-Analysis and Meta-Regression.” Diabetology & Metabolic Syndrome, vol. 11, no. 1, 23 July 2019, doi:10.1186/s13098-019-0453-7. * Zhou, Joseph, et al. “Metformin: An Old Drug with New Applications.” International Journal of Molecular Sciences, vol. 19, no. 10, 21 Sept. 2018, p. 2863., doi:10.3390/ijms19102863.
* Male hormones are referred to as [androgens](https://nabtahealth.com/glossary/androgen/). * The most well-known male hormones are [testosterone](https://nabtahealth.com/glossary/testosterone/) and androstenedione. * These male hormones are present in women as well as men, and they are essential for maintaining the right hormonal balance. * Symptoms of excess male hormones include acne, [alopecia](https://nabtahealth.com/glossary/alopecia/) (hairloss) and [hirsutism](https://nabtahealth.com/glossary/hirsutism/) (excess hair). * 70% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) experience excess male hormones ([hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/)) and 10-30% of cases of excess male hormones will be due to a different disorder. #### What do male hormones ([androgens](https://nabtahealth.com/glossary/androgen/)) do in women? In women, [androgens](https://nabtahealth.com/glossary/androgen/) are secreted by the [ovaries](https://nabtahealth.com/glossary/ovaries/) and the adrenal gland. [Testosterone](https://nabtahealth.com/glossary/testosterone/) is a precursor of oestradiol and therefore, the availability of [testosterone](https://nabtahealth.com/glossary/testosterone/) has a direct effect on how much oestradiol is produced. Male hormones are involved in enhancing a woman’s libido and maintaining a healthy reproductive system. They are implicated in [](https://nabtahealth.com/what-is-puberty/)[puberty](https://nabtahealth.com/glossary/puberty/) and, given intra vaginally, they can improve signs of [vaginal atrophy](https://nabtahealth.com/5-reasons-why-you-may-be-experiencing-vaginal-dryness/) during the [](https://nabtahealth.com/about-the-three-stages-of-menopause/)[menopause](https://nabtahealth.com/glossary/menopause/). #### Low androgen levels in women The importance of [androgens](https://nabtahealth.com/glossary/androgen/) in women is demonstrated by the ill effects that are felt when their synthesis is disrupted in any way. An androgen deficiency in females can cause a reduction in sexual desire (low libido), fatigue and a general lowering of mood. There are limited, small scale studies suggesting that [androgens](https://nabtahealth.com/glossary/androgen/) exert protective effects on the heart and brain; and low [testosterone](https://nabtahealth.com/glossary/testosterone/) concentrations have also been associated with a decline in bone mineral density. These studies all require further validation, but they do hint at a physiologically beneficial role for [testosterone](https://nabtahealth.com/glossary/testosterone/) and the other [androgens](https://nabtahealth.com/glossary/androgen/) in females. Serum levels of androstenedione drop markedly after the [menopause](https://nabtahealth.com/glossary/menopause/), however, levels of [testosterone](https://nabtahealth.com/glossary/testosterone/) are usually maintained, which suggests that the [ovaries](https://nabtahealth.com/glossary/ovaries/) are still producing [testosterone](https://nabtahealth.com/glossary/testosterone/). Women who undergo an [oophorectomy](https://nabtahealth.com/glossary/oophorectomy/) typically experience a fall in serum [testosterone](https://nabtahealth.com/glossary/testosterone/) levels of approximately 50%, as production shifts entirely to the adrenal gland. Whilst the prospect of androgen replacement therapy seems appealing, to date, it is only recommended for the treatment of hypoactive sexual desire disorder and not for other cases of suspected androgen deficiency. #### High androgen levels in women The term applied to those with an excess of [androgens](https://nabtahealth.com/glossary/androgen/) is [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). The clinical manifestations of this can include acne, [](https://nabtahealth.com/how-to-manage-facial-hair/)[hirsutism](https://nabtahealth.com/glossary/hirsutism/) and [](https://nabtahealth.com/coping-with-pcos-hair-loss/)[alopecia](https://nabtahealth.com/glossary/alopecia/). Biochemically, the condition is defined by an increase in circulating [androgens](https://nabtahealth.com/glossary/androgen/) in the serum. Excess [androgens](https://nabtahealth.com/glossary/androgen/) can have a long-term effect on health, increasing the risk of conditions including type 2 diabetes, high blood pressure and heart disease (somewhat confusingly, both abnormally low and abnormally high [testosterone](https://nabtahealth.com/glossary/testosterone/) levels have been linked to an increased risk of cardiovascular disease). The impact of high androgen levels on a female’s self-confidence should also not be overlooked. Women who are experiencing significant [alopecia](https://nabtahealth.com/glossary/alopecia/) or [hirsutism](https://nabtahealth.com/glossary/hirsutism/) are at increased risk of struggling with image-related insecurities. There are a number of recognised causes of [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/), these include: #### [Androgens](https://nabtahealth.com/glossary/androgen/) (male hormones) and Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) Perhaps the most well known disorder of androgen excess is [](https://nabtahealth.com/what-is-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/). Approximately 70% of women with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (excess male hormones) will receive a diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/). The condition can be challenging to both diagnose and manage, as it is a syndrome, which presents differently from patient to patient. In fact, diagnosis is usually performed by a process of exclusion, whereby other possible conditions are systematically ruled out. According to the Rotterdam criteria, to be diagnosed with [PCOS](https://nabtahealth.com/glossary/pcos/), a female must present with two out of the following three symptoms: * [Hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (excess male hormones) * [Anovulation](https://nabtahealth.com/glossary/anovulation/) (lack of [ovulation](https://nabtahealth.com/glossary/ovulation/)) * Polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/). However, other guidelines, such as those by the National Institute of Health, consider the condition to be primarily one of androgen excess, which in turn gives rise to the other physical characteristics of the syndrome. The preferred approach for the management of [PCOS](https://nabtahealth.com/glossary/pcos/) is making [lifestyle adjustments](https://nabtahealth.com/is-it-possible-to-reverse-pcos/), such as losing weight. This has been shown to significantly improve the symptoms of the condition. Whilst the majority of women with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) will have [PCOS](https://nabtahealth.com/glossary/pcos/), 10-30% of cases of androgen excess will be due to a different disorder. #### Congenital [Adrenal Hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/) The Congenital Adrenal Hyperplasias (CAHs) are a group of disorders characterised by impaired [cortisol](https://nabtahealth.com/glossary/cortisol/) secretion because the enzymes that are normally responsible for its production are missing or ineffective. These disorders are [autosomal recessive](https://nabtahealth.com/glossary/autosomal-recessive/), which means that to inherit them you need to inherit a mutated gene from both parents. Whilst the classical form most often presents in childhood, the non-classical form is usually diagnosed after [puberty](https://nabtahealth.com/glossary/puberty/), or in adulthood, with symptoms very similar to those seen in women with [PCOS](https://nabtahealth.com/glossary/pcos/), including [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/), [infertility](https://nabtahealth.com/glossary/infertility/) and disrupted menstrual cycles. In CAH the adrenal gland is the source of the excess [androgens](https://nabtahealth.com/glossary/androgen/), rather than the [ovaries](https://nabtahealth.com/glossary/ovaries/). The prevalence varies according to ethnicity, with Ashkenazi Jews and Europeans of Latin descent at most risk. Between 1 and 10% of women with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) will discover that they have non-classical CAH. #### Androgen-secreting neoplasms Androgen-secreting neoplasms of the ovary or adrenal gland are rare. Ovarian androgen-secreting neoplasms are responsible for between 0.1 and 0.3% of cases of [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/); adrenal androgen-secreting neoplasms are even rarer than this. It is, however, important to check for their presence as some are cancerous and will require urgent treatment. The symptoms of neoplasms often mimic those of [PCOS](https://nabtahealth.com/glossary/pcos/), but their onset is usually rapid and effects worsen with time. Women with these sorts of neoplasms will usually experience severe [hirsutism](https://nabtahealth.com/glossary/hirsutism/), [alopecia](https://nabtahealth.com/glossary/alopecia/) and acne. They may also observe a change in body shape, with breasts becoming smaller and a loss of feminine body contours. Ovarian neoplasms might be palpable during a pelvic exam, otherwise they should be easy to identify using ultrasound. #### Cushing’s Syndrome [Cushing’s syndrome](https://nabtahealth.com/what-is-cushings-syndrome/) is a rare condition characterised by an excess of [cortisol](https://nabtahealth.com/glossary/cortisol/). This leads to an increase in the secretion of adrenal [androgens](https://nabtahealth.com/glossary/androgen/), contributing to symptoms such as [hirsutism](https://nabtahealth.com/glossary/hirsutism/) and acne that are synonymous with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). Fewer than 1% of women with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) will be diagnosed with Cushing’s syndrome. #### [Insulin Resistance](https://nabtahealth.com/glossary/insulin-resistance/) Approximately 3% of women with [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) will be diagnosed with hyperandrogenic-insulin resistant-acanthosis nigricans syndrome. Women with this condition have severe metabolic abnormalities, are usually overweight and are at increased risk of developing type 2 diabetes mellitus (T2DM). They have extensive [acanthosis nigricans](https://nabtahealth.com/what-is-acanthosis-nigricans/) and are usually severely hyperandrogenic, with some [virilisation](https://nabtahealth.com/glossary/virilisation/), meaning that they are developing male characteristics, such as a deep voice and increased muscle mass. A condition of high [](https://nabtahealth.com/what-is-insulin-resistance/)[insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) will normally be diagnosed by measuring the levels of circulating insulin. The long term consequences of the condition, such as [hypertension](https://nabtahealth.com/glossary/hypertension/) and T2DM, necessitate prompt and effective management. Women diagnosed with [PCOS](https://nabtahealth.com/glossary/pcos/) are prone to have [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and develop type 2 diabetes mellitus (T2DM). #### Idiopathic [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) Some women exhibit symptoms of [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) but do not fulfil the criteria for [PCOS](https://nabtahealth.com/glossary/pcos/) and do not experience other [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms or the other conditions described above. In these cases, the reason for their androgen excess remains unknown and they are diagnosed with idiopathic [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). #### Environmental [androgens](https://nabtahealth.com/glossary/androgen/)/[endocrine disruptors](https://nabtahealth.com/glossary/endocrine-disruptors/) [Endocrine disruptors](https://nabtahealth.com/glossary/endocrine-disruptors/) are a cause of great concern, due to their widespread prevalence. They are found in a large number of everyday cleaning and beauty products and they exert their detrimental effects by upsetting the normal hormonal balance. Many environmental [androgens](https://nabtahealth.com/glossary/androgen/) pose an additional risk because they also cross the placental barrier, creating a potentially harmful hyperandrogenic foetal environment. Long-term effects are unclear, but future metabolic and reproductive disorders are a concern for these babies. Two well characterised examples of [endocrine disruptors](https://nabtahealth.com/glossary/endocrine-disruptors/) that have androgenic activity are triclocarban (TCC) and nicotine. TCC is an antimicrobial found in, amongst other products, soaps, clothing, carpets and plastics. It seems to regulate the activity of the androgen receptors, affecting the availability of [testosterone](https://nabtahealth.com/glossary/testosterone/). Nicotine is found in cigarettes and can cross the placental barrier, accumulating in the [amniotic fluid](https://nabtahealth.com/glossary/amniotic-fluid/). Women smokers have increased [testosterone](https://nabtahealth.com/glossary/testosterone/) levels. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#ef968e83838eaf818e8d9b8e878a8e839b87c18c8082) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Azziz, Ricardo, et al. “The Androgen Excess and [PCOS](https://nabtahealth.com/glossary/pcos/) Society Criteria for the Polycystic Ovary Syndrome: the Complete Task Force Report.” Fertility and Sterility, vol. 91, no. 2, Feb. 2009, pp. 456–488., doi:10.1016/j.fertnstert.2008.06.035. * Davis, Susan R, and Sarah Wahlin-Jacobsen. “[Testosterone](https://nabtahealth.com/glossary/testosterone/) in Women—the Clinical Significance.” The Lancet Diabetes & Endocrinology, vol. 3, no. 12, 7 Sept. 2015, pp. 980–992., doi:10.1016/s2213-8587(15)00284-3. * Galan, N. “Late-Onset Congenital [Adrenal Hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/) .” Very Well Health, [www.verywellhealth.com/congenital-adrenal-hyperplasia-overview-2616550](http://www.verywellhealth.com/congenital-adrenal-hyperplasia-overview-2616550). Updated December 20, 2018. * Hammes, Stephen R., and Ellis R. Levin. “Impact of Estrogens in Males and [Androgens](https://nabtahealth.com/glossary/androgen/) in Females.” Journal of Clinical Investigation, vol. 129, no. 5, 1 May 2019, pp. 1818–1826., doi:10.1172/jci125755. * Hewlett, M, et al. “Prenatal Exposure to [Endocrine Disruptors](https://nabtahealth.com/glossary/endocrine-disruptors/): A Developmental Etiology for Polycystic Ovary Syndrome.” Reproductive Sciences, vol. 24, no. 1, Jan. 2017, pp. 19–27., doi:10.1177/1933719116654992. * Snyder, Peter J. “Editorial: The Role of [Androgens](https://nabtahealth.com/glossary/androgen/) in Women.” The Journal of Clinical Endocrinology & [Metabolism](https://nabtahealth.com/glossary/metabolism/), vol. 86, no. 3, 1 Mar. 2001, pp. 1006–1007., doi:10.1210/jcem.86.3.7369. * Witchel, S F. “Nonclassic Congenital [Adrenal Hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/).” Current Opinion in Endocrinology, Diabetes and Obesity, vol. 19, no. 3, June 2012, pp. 151–158., doi:10.1097/MED.0b013e3283534db2.
* It is possible to reverse [PCOS](https://nabtahealth.com/glossary/pcos/). * A syndrome with multiple symptoms, being diagnosed with [PCOS](https://nabtahealth.com/glossary/pcos/) does not mean you will have it forever. A common misconception that people have about [PCOS](https://nabtahealth.com/glossary/pcos/) is that once diagnosed it is there for life. This is simply not true. [PCOS](https://nabtahealth.com/glossary/pcos/) is better characterised as a syndrome, or a set of interlinked symptoms. Some women will experience many, others barely any. The three main symptoms, as recognised by the medical community, are: * [Anovulation](https://nabtahealth.com/glossary/anovulation/) (lack of [ovulation](https://nabtahealth.com/glossary/ovulation/)) * [Hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (excess male hormones) * [Polycystic](https://nabtahealth.com/en/hints-and-tips/four-types-of-PCOS) [ovaries](https://nabtahealth.com/glossary/ovaries/). [At least two of these are required for a clinical diagnosis.](https://nabtahealth.com/what-is-pcos/) However, many women with [PCOS](https://nabtahealth.com/glossary/pcos/) report other symptoms such as [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/), obesity, [infertility](https://nabtahealth.com/glossary/infertility/) and increased susceptibility to inflammatory conditions. #### **How can I relieve my [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms?** To reverse [PCOS](https://nabtahealth.com/glossary/pcos/) you need to think about [managing](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms. Certain **medications** will mask the symptoms; the oral contraceptive pill will reduce the effects of having an excess of male hormones, clomiphene citrate will boost fertility, [metformin](https://nabtahealth.com/en/hints-and-tips/what-is-metformin) will control your blood sugar levels and reduce the risk of type 2 diabetes. However, the likelihood with all of these is that once you stop the treatment, the symptoms will return. An altogether more sustainable approach is to make **lifestyle changes and dietary modifications** that will not only help in the short-term, but also avoid the recurrence of [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms at a later date. #### **What lifestyle changes can alleviate [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms?** Lifestyle changes do not have to be drastic; lose weight, exercise more and supplement your diet with vitamins and minerals that are proven to help with [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms. Magnesium is a good example; it reduces insulin levels and has anti-inflammatory properties. Try to better understand your body; which foods you tolerate well and which you do not; how to exercise effectively, without putting your body into a stressed state. Women with [PCOS](https://nabtahealth.com/glossary/pcos/) frequently test positively for inflammatory markers. However, these markers are also seen in people with diabetes and/or clinical obesity, both of which [regularly present alongside](https://nabtahealth.com/factors-that-contribute-to-transient-pcos-like-symptoms/) [PCOS](https://nabtahealth.com/glossary/pcos/). This further highlights the need to eat a well balanced diet, with an emphasis on weight loss. [Endocrine disruptors](https://nabtahealth.com/glossary/endocrine-disruptors/), present in a vast array of cleaning and beauty products, can also alter hormonal [homeostasis](https://nabtahealth.com/glossary/homeostasis/), aggravating [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms. **You can reverse [PCOS](https://nabtahealth.com/glossary/pcos/) and adopt a holistic approach to your care. This is rapidly becoming the preferred treatment option for many women suffering from [PCOS](https://nabtahealth.com/glossary/pcos/) and [PCOS](https://nabtahealth.com/glossary/pcos/) side effects.** Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#b2cbd3deded3f2dcd3d0c6d3dad7d3dec6da9cd1dddf) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * El Hayak, S, et al. “Poly Cystic Ovarian Syndrome: An Updated Overview.” _Frontiers in Physiology_, vol. 7, 5 Apr. 2016, p. 124., doi:10.3389/fphys.2016.00124. * Patel, S. “Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)), an Inflammatory, Systemic, Lifestyle Endocrinopathy.” _The Journal of Steroid Biochemistry and Molecular Biology_, vol. 182, Sept. 2018, pp. 27–36., doi:10.1016/j.jsbmb.2018.04.008.
* It is possible for women to have [PCOS](https://nabtahealth.com/glossary/pcos/) but still have regular periods. * [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms do not always include irregular periods; * Many women with with [PCOS](https://nabtahealth.com/glossary/pcos/) but regular periods do also experience difficulties with [ovulation](https://nabtahealth.com/glossary/ovulation/). Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is the most common endocrine condition affecting females of reproductive age, with a suspected prevalence rate of between 4 and 10%. It is a challenging condition to both diagnose and treat as it presents with a variety of symptoms that can differ in intensity and impact from patient to patient. One of the most common symptoms is **irregular periods**, which affect some, but not all women with _[PCOS](https://nabtahealth.com/glossary/pcos/) symptoms_. A diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/) is often made after the exclusion of other conditions. In 2003, the Rotterdam consensus established a [set of guidelines](https://nabtahealth.com/what-is-pcos/) to assist with diagnosis. These guidelines stated that for a diagnosis to be made, patients should present with **two out of three** of the following symptoms: * Oligo/[anovulation](https://nabtahealth.com/glossary/anovulation/). * Clinical or biochemical [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). * Polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/). Whilst not part of the standard diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/), [](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/)[insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and obesity are also heavily associated with the condition. #### **[PCOS](https://nabtahealth.com/glossary/pcos/) and fertility** Not all women with [PCOS](https://nabtahealth.com/glossary/pcos/) have fertility issues, but a significant number do. Many women first identify a problem when they [struggle to conceive](https://nabtahealth.com/pcos-and-pregnancy/) and it is only upon undergoing investigations for [infertility](https://nabtahealth.com/glossary/infertility/) that they receive a [PCOS](https://nabtahealth.com/glossary/pcos/) diagnosis. As many as 70-80% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) will have fertility problems and the condition is the primary cause of [anovulation](https://nabtahealth.com/glossary/anovulation/) in women of reproductive age. One of the most obvious signs that there is an ovulatory issue is menstrual cycle disturbances. 75-85% of patients with [PCOS](https://nabtahealth.com/glossary/pcos/) will have [irregular menstrual cycles](https://nabtahealth.com/why-are-my-periods-irregular/). Infrequent periods, also known as oligomenorrhoea, occur when a female has less than 8 periods a year and/or an interval of 35 days or more between bleeding. 80-90% of women who seek medical assistance for oligomenorrhoea will be diagnosed with [PCOS](https://nabtahealth.com/glossary/pcos/). Thus, it is very common for women with [PCOS](https://nabtahealth.com/glossary/pcos/) to have irregular periods. Is it, however, possible to have _regular periods_, and still be diagnosed with [PCOS](https://nabtahealth.com/glossary/pcos/)? The answer to this is yes. If you are concerned you have [PCOS](https://nabtahealth.com/glossary/pcos/), take an [at-home](https://nabtahealth.com/product/pcos-test/) [PCOS](https://nabtahealth.com/glossary/pcos/) blood test. It is a quick, discreet and convenient way to find out whether you have polycystic ovary syndrome. Based on your test results, you will get tailored advice to help you correct any imbalances or deficiencies. #### **Diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/) but periods are regular** There are two main scenarios that might result in a female having [PCOS](https://nabtahealth.com/glossary/pcos/) with regular periods. **1** In adhering to the Rotterdam guidelines, only two out of three symptoms are required for a diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/) to be made. Therefore, a female might have polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/) and exhibit signs of [](https://nabtahealth.com/masculine-hormones-in-women/)[hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/), but maintain regular ovulatory cycles. With regular ovulatory cycles, her periods will probably also be regular, but her other symptoms would be sufficient for a positive diagnosis. Women who ovulate regularly are less likely to experience [infertility](https://nabtahealth.com/glossary/infertility/). **2** [Ovulation](https://nabtahealth.com/glossary/ovulation/) can be severely disrupted with no obvious effects on the regularity of menstruation. 20-50% of hyperandrogenic women with normal periods, have chronic anovulatory cycles, and regular periods are not a guarantee that [ovulation](https://nabtahealth.com/glossary/ovulation/) is occurring. This can be a particularly difficult situation for those women who are using their periods to track their fertile days with the aim of falling pregnant. Without [ovulation](https://nabtahealth.com/glossary/ovulation/), fertilisation cannot occur. The only way to confirm the presence or absence of [ovulation](https://nabtahealth.com/glossary/ovulation/) clinically is to have a blood test; however, women who are experiencing anovulatory cycles might find that they do not experience typical premenstrual symptoms, such as bloating, irritability and sore breasts. Clinical confirmation of [ovulation](https://nabtahealth.com/glossary/ovulation/) comes from monitoring [serum](https://nabtahealth.com/what-happens-if-my-progesterone-levels-are-too-low/) [progesterone](https://nabtahealth.com/glossary/progesterone/) levels. Normally, immediately after [ovulation](https://nabtahealth.com/glossary/ovulation/), [progesterone](https://nabtahealth.com/glossary/progesterone/) levels will rise rapidly, marking the luteal phase of the cycle. It is not unusual for [progesterone](https://nabtahealth.com/glossary/progesterone/) levels to reach 10ng/mL. If levels remain below 3-4 ng/mL [ovulation](https://nabtahealth.com/glossary/ovulation/) is extremely unlikely to have occurred. #### **The masking effects of the oral contraceptive pill** There is another scenario whereby a woman may believe she is having regular periods following a [PCOS](https://nabtahealth.com/glossary/pcos/) diagnosis. Many women take the [oral contraceptive pill](https://nabtahealth.com/the-oral-contraceptive-pill/); and its usage today extends far beyond solely preventing pregnancy. Women take it to manage heavy periods, to alleviate the symptoms of the peri-[menopause](https://nabtahealth.com/glossary/menopause/) and to reduce the effects of [premenstrual syndrome](https://nabtahealth.com/glossary/premenstrual-syndrome/). It is a valuable tool in the [management of](https://nabtahealth.com/what-medications-are-recommended-for-endometriosis/) [endometriosis](https://nabtahealth.com/glossary/endometriosis/) and its anti-androgenic properties mean that it is often given to women with [PCOS](https://nabtahealth.com/glossary/pcos/). The combined oral contraceptive pill results in monthly bleeds, and thus, it is not unreasonable to assume that it is also effectively restoring cycle regularity. However, these are withdrawal bleeds rather than normal menstruation and it is highly probable that unless appropriate [lifestyle changes](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) have been implemented, once treatment ceases, cycles that were previously irregular will become that way once again. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#265f474a4a476648474452474e43474a524e0845494b) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Azziz, Ricardo, et al. “The Androgen Excess and [PCOS](https://nabtahealth.com/glossary/pcos/) Society Criteria for the Polycystic Ovary Syndrome: the Complete Task Force Report.” Fertility and Sterility, vol. 91, no. 2, Feb. 2009, pp. 456–488., doi:10.1016/j.fertnstert.2008.06.035. * “Long-Term Consequences of Polycystic Ovary Syndrome.” Royal College of Obstetricians and Gynaecologists, Nov. 2014, [www.rcog.org.uk/globalassets/documents/guidelines/gtg\_33.pdf](http://www.rcog.org.uk/globalassets/documents/guidelines/gtg_33.pdf). * “Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)).” ACOG, June 2017, [www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-](http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS)[PCOS](https://nabtahealth.com/glossary/pcos/). * Teede, H, et al. “Polycystic Ovary Syndrome: a Complex Condition with Psychological, Reproductive and Metabolic Manifestations That Impacts on Health across the Lifespan.” BMC Medicine, vol. 8, no. 1, 30 June 2010, doi:10.1186/1741-7015-8-41.
Polycystic ovary syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is a common hormonal disorder that can affect a woman’s ability to get pregnant. While having [PCOS](https://nabtahealth.com/glossary/pcos/) does not necessarily increase a woman’s chance of [miscarriage](https://nabtahealth.com/glossary/miscarriage/), it can make it more difficult for her to conceive and can also increase her risk of other pregnancy complications. [PCOS](https://nabtahealth.com/glossary/pcos/) is a condition in which the [ovaries](https://nabtahealth.com/glossary/ovaries/) produce an excess of male hormones, which can interfere with the development of eggs and make it more difficult for the eggs to be released from the [ovaries](https://nabtahealth.com/glossary/ovaries/). This can make it more difficult for a woman with [PCOS](https://nabtahealth.com/glossary/pcos/) to get pregnant. * There is a known link between [PCOS](https://nabtahealth.com/glossary/pcos/) and [miscarriage](https://nabtahealth.com/glossary/miscarriage/), but there is not enough data on this topic. * There is no solid evidence that any drugs can mitigate the risk of [miscarriage](https://nabtahealth.com/glossary/miscarriage/). * Choosing a healthy lifestyle is one of the key ways you can increase your chances of staying pregnant and preventing [miscarriage](https://nabtahealth.com/glossary/miscarriage/). A link between [PCOS](https://nabtahealth.com/glossary/pcos/) and [miscarriage](https://nabtahealth.com/glossary/miscarriage/) was first described in the late 1980s and yet, despite this, in the past 30 years very little progress has been made. We are still not sure why women with [PCOS](https://nabtahealth.com/glossary/pcos/) are at greater risk of miscarrying and, perhaps more importantly for those affected, we are no closer to finding a solution. It almost goes without saying that this is an area of research that desperately needs more attention and resources. Here we explore the limited data available, discuss why the need for answers is getting greater, and suggest what you can do to maximise your chances of falling pregnant and staying pregnant. You can track your pregnancy free of charge [using the Nabta App](https://nabtahealth.com/our-platform/nabta-app/). **What does the data suggest about [PCOS](https://nabtahealth.com/glossary/pcos/) and [Miscarriage](https://nabtahealth.com/glossary/miscarriage/)?** ----------------------------------------------------------------------------------------------------------------------------------------------------- Women with [PCOS](https://nabtahealth.com/glossary/pcos/) often struggle to conceive; in fact, the condition is considered to be one of the [leading causes of](https://nabtahealth.com/causes-of-female-infertility-failure-to-ovulate/) [infertility](https://nabtahealth.com/glossary/infertility/) in females. The problem is that once pregnant, those women with [PCOS](https://nabtahealth.com/glossary/pcos/) are also at increased risk of going through the trauma of one, or even multiple, [miscarriages](https://nabtahealth.com/miscarriage-101/). Women with [PCOS](https://nabtahealth.com/glossary/pcos/) are three times more likely to miscarry than those without [PCOS](https://nabtahealth.com/glossary/pcos/). There is some evidence that women who suffer recurrent miscarriages are more likely to have [polycystic](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/) [ovaries](https://nabtahealth.com/glossary/ovaries/), but no proof that this abnormal ovarian morphology is causing pregnancy loss. There is also very little data to support the idea that increased levels of luteinising hormone or [testosterone](https://nabtahealth.com/glossary/testosterone/) are implicated in [miscarriage](https://nabtahealth.com/glossary/miscarriage/). One of the biggest issues with the work that has been completed to date is that many of the studies rely on retrospective evidence. The accuracy and reproducibility of the results is dependent on participant recollection. As a result, many of the large scale reviews have deemed the evidence that is currently available to be of low quality and inconclusive. Also, the variation in the criteria used to define [PCOS](https://nabtahealth.com/glossary/pcos/) before the Rotterdam criteria became the [gold](https://nabtahealth.com/glossary/gold/) standard in 2003, led to some inconsistencies in the association between [PCOS](https://nabtahealth.com/glossary/pcos/) and miscarriages. **Why does the association between [PCOS](https://nabtahealth.com/glossary/pcos/) and [miscarriage](https://nabtahealth.com/glossary/miscarriage/) urgently require further work?** ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- [](https://nabtahealth.com/what-is-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/) is a medical condition that is not going to disappear any time soon. In fact, the percentage of women affected by it is likely to increase over the coming years. [PCOS](https://nabtahealth.com/glossary/pcos/) is [strongly associated with obesity and](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/) [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/); and, whilst these two conditions are increasing in prevalence across the developed world, an unfortunate consequence of this will be that more women will find themselves facing the realities of a [](https://nabtahealth.com/problems-with-traditional-diagnosis-of-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/) diagnosis. We know that women with [PCOS](https://nabtahealth.com/glossary/pcos/) who do conceive are at risk of further pregnancy complications, including [](https://nabtahealth.com/gestational-diabetes-8-things-you-should-know/)[gestational diabetes](https://nabtahealth.com/glossary/gestational-diabetes/), [](https://nabtahealth.com/what-is-preeclampsia/)[preeclampsia](https://nabtahealth.com/glossary/preeclampsia/) and premature delivery. This is financially costly, placing an increasing burden on healthcare systems across the world; but it is also emotionally draining for those couples who have to go through it. Experiencing a [miscarriage](https://nabtahealth.com/glossary/miscarriage/) can be a devastating experience. There can never be a right or wrong way of coping with and managing your loss. However, for many women, closure, or acceptance, is possible once they understand why something has happened. We need to improve our knowledge on [](https://nabtahealth.com/pcos-and-pregnancy/)[PCOS](https://nabtahealth.com/glossary/pcos/) and pregnancy; we need to better understand why [PCOS](https://nabtahealth.com/glossary/pcos/) increases the risk of [miscarriage](https://nabtahealth.com/glossary/miscarriage/); and, perhaps above all, we need to give those women who have experienced a loss, answers. **What can you do to manage your risk of miscarrying and increase your chances of a healthy pregnancy?** -------------------------------------------------------------------------------------------------------- As already discussed, there is significant work to be done to support the risk of [PCOS](https://nabtahealth.com/glossary/pcos/) and [miscarriage](https://nabtahealth.com/glossary/miscarriage/). Some reports have suggested that [ovulation](https://nabtahealth.com/glossary/ovulation/) induction agents, such as clomiphene citrate and [metformin](https://nabtahealth.com/i-have-pcos-should-i-take-metformin/), might improve live birth rates. In fact, metformin is not strictly an [ovulation](https://nabtahealth.com/glossary/ovulation/) inducer, it is used to treat [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/), and has, therefore, been used ‘off-label’ to manage some of the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/). There is limited evidence that it improves [ovulation](https://nabtahealth.com/glossary/ovulation/) rates. There is no solid evidence that either of these drugs reduce the risk of [miscarriage](https://nabtahealth.com/glossary/miscarriage/) and the data across different studies remains conflicting. Whilst this may all be sounding a little depressing, there is one key thing that should be remembered; [many of the symptoms of](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/) can be alleviated by making healthy lifestyle decisions. Losing weight, exercising more, making considered choices with regards to your [diet](https://nabtahealth.com/eating-to-conceive/), these are all things that can help to improve menstrual cycle regularity. This in turn, increases your chances of getting, and staying, pregnant. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#354c54595954755b545741545d505459415d1b565a58) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Cocksedge Karen, et al., “How common is polycystic ovary syndrome in recurrent [miscarriage](https://nabtahealth.com/glossary/miscarriage/)?” _Reproductive Biomedicine Online_, 2009 Oct;19(4):572-6. doi: 10.1016/j.rbmo.2009.06.003. PMID: 19909600. * “Does [PCOS](https://nabtahealth.com/glossary/pcos/) Affect Pregnancy?” _Eunice Kennedy Shriver National Institute of Child Health and Human Development_, U.S. Department of Health and Human Services, [www.nichd.nih.gov/health/topics/](http://www.nichd.nih.gov/health/topics/pcos/more_information/FAQs/pregnancy)[pcos](https://nabtahealth.com/glossary/pcos/)/more\_information/FAQs/pregnancy. * Kaur, R and Gupta, K. “Endocrine Dysfunction and Recurrent Spontaneous Abortion: An Overview.” _International Journal of Applied and Basic Medical Research_, vol. 6, no. 2, 2016, pp. 79–83., doi:10.4103/2229-516x.179024. * Legro, Richard S., et al. “Clomiphene, Metformin, or Both for [Infertility](https://nabtahealth.com/glossary/infertility/) in the Polycystic Ovary Syndrome.” _New England Journal of Medicine_, vol. 356, no. 6, 8 Feb. 2007, pp. 551–566., doi:10.1056/nejmoa063971. * Mills, Ginevra, et al. “Associations between Polycystic Ovary Syndrome and Adverse Obstetric and [Neonatal](https://nabtahealth.com/glossary/neonatal/) Outcomes: a Population Study of 9.1 Million Births.” _Human Reproduction_, vol. 35, no. 8, 9 July 2020, pp. 1914–1921., doi:10.1093/humrep/deaa144. * Rai, Raj, et al. “Polycystic [Ovaries](https://nabtahealth.com/glossary/ovaries/) and Recurrent [Miscarriage](https://nabtahealth.com/glossary/miscarriage/)—a Reappraisal.” _Human Reproduction_, vol. 15, no. 3, 1 Mar. 2000, pp. 612–615., doi:10.1093/humrep/15.3.612. * Sagle, M., et al. “Recurrent Early [Miscarriage](https://nabtahealth.com/glossary/miscarriage/) and Polycystic [Ovaries](https://nabtahealth.com/glossary/ovaries/).” _Bmj_, vol. 297, no. 6655, 22 Oct. 1988, pp. 1027–1028., doi:10.1136/bmj.297.6655.1027. * Sharpe, Abigail, et al. “Metformin for [Ovulation](https://nabtahealth.com/glossary/ovulation/) Induction (Excluding Gonadotrophins) in Women with Polycystic Ovary Syndrome.” _Cochrane Database of Systematic Reviews_, 17 Dec. 2019, doi:10.1002/14651858.cd013505.
If you are tracking your menstrual cycle, you may want to understand the luteal phase, Low [progesterone](https://nabtahealth.com/glossary/progesterone/) levels include spotting and [miscarriage](https://nabtahealth.com/glossary/miscarriage/). Under normal conditions, [progesterone](https://nabtahealth.com/glossary/progesterone/) levels rise during the luteal phase of the menstrual cycle and peak 6-8 days after [ovulation](https://nabtahealth.com/glossary/ovulation/). [Progesterone](https://nabtahealth.com/glossary/progesterone/) levels during the menstrual cycle ------------------------------------------------------------------------------------------------ The menstrual cycle is split into the follicular phase and the luteal phase. The follicular phase is from day one of menstruation until [ovulation](https://nabtahealth.com/glossary/ovulation/), which is triggered by a surge in levels of luteinising hormone ([LH](https://nabtahealth.com/glossary/lh/)). The luteal phase of the cycle follows [ovulation](https://nabtahealth.com/glossary/ovulation/) and is always the 10-14 days before the next monthly period starts, regardless of ‘normal’ cycle length. [Progesterone](https://nabtahealth.com/glossary/progesterone/) quantity change during the cycle: * Follicular phase – less than 1.5ng/mL. * [Ovulation](https://nabtahealth.com/glossary/ovulation/) – levels start to rise and peak after 6-8 days. * Luteal phase – levels reach 7-10ng/mL. [](https://nabtahealth.com/wp-content/uploads/2020/03/Nabta-Mar-26th_pogesterone-levels_2.png) Without [ovulation](https://nabtahealth.com/glossary/ovulation/), the levels of [progesterone](https://nabtahealth.com/glossary/progesterone/) do not increase. Thus, checking [progesterone](https://nabtahealth.com/glossary/progesterone/) levels midway through the luteal phase (usually day 21 or 22 of the cycle) is one way of assessing whether or not [ovulation](https://nabtahealth.com/glossary/ovulation/) has occurred. If fertility status is being assessed luteal phase [progesterone](https://nabtahealth.com/glossary/progesterone/) levels will often be measured alongside [Basal Body Temperature](https://nabtahealth.com/charting-your-basal-body-temperature-bbt/) (BBT). BBT should rise by 0.5°C after [ovulation](https://nabtahealth.com/glossary/ovulation/). If blood serum [progesterone](https://nabtahealth.com/glossary/progesterone/) levels do not get above 3-4ng/mL during the luteal phase of the cycle, then it is highly unlikely that [ovulation](https://nabtahealth.com/glossary/ovulation/) has occurred. If timed correctly to coincide with the midpoint of the luteal phase, the amount of [progesterone](https://nabtahealth.com/glossary/progesterone/) can reach 10ng/mL; This will be 5-7 days before you get your period and is the point at which levels of this hormone are at their highest. If you are concerned that your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are too low, find out quickly and conveniently by taking an [at-home women’s health blood test](https://nabtahealth.com/product/womens-health-test/). The results will allow you to make informed decisions about your next steps. What does it mean if you have low [progesterone](https://nabtahealth.com/glossary/progesterone/) levels? -------------------------------------------------------------------------------------------------------- If [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are low there are a few factors to consider. Firstly, at what stage in the cycle were they checked? During the follicular phase, which comes before [ovulation](https://nabtahealth.com/glossary/ovulation/), It will be very low, usually below 1.5ng/mL. If you want to check that [ovulation](https://nabtahealth.com/glossary/ovulation/) has occurred you need to wait until the second half of the cycle, when a rise in [progesterone](https://nabtahealth.com/glossary/progesterone/) is a good indicator of [ovulation](https://nabtahealth.com/glossary/ovulation/). If you are on most forms of hormonal birth control, including the combined [oral contraceptive pill](https://nabtahealth.com/the-oral-contraceptive-pill/), endogenous [progesterone](https://nabtahealth.com/glossary/progesterone/) is suppressed, so quantity will be below. If you are postmenopausal, you will no longer be ovulating and as a result, you will no longer experience a mid-luteal peak in [progesterone](https://nabtahealth.com/glossary/progesterone/) levels. Serum [progesterone](https://nabtahealth.com/glossary/progesterone/) levels will be very low, often less than 0.5ng/mL. Finally, levels are inherently variable. They can fluctuate dramatically in a 90 minute time period, so it might just be a matter of repeating the test at a different time. If, after taking all of these points into consideration, luteal phase [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are still low, you will need to consider that [ovulation](https://nabtahealth.com/glossary/ovulation/) may not be happening and look into the reasons why. The occasional anovulatory cycle is normal; it might happen when you have only just started your periods, or if you are recovering from a medical problem, such as hypothalamic [amenorrhoea](https://nabtahealth.com/glossary/amenorrhoea/), or have just come off the pill. In these instances wait a few months and see whether your cycles become regular overtime. However, if the lack of [ovulation](https://nabtahealth.com/glossary/ovulation/) and [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are constant and sustained, [](https://nabtahealth.com/what-is-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/) is something that should be considered. In many cases, implementing [lifestyle changes](https://nabtahealth.com/is-it-possible-to-reverse-pcos/), such as losing weight, can help to rectify the symptoms of the condition, restore [ovulation](https://nabtahealth.com/glossary/ovulation/) and ensure levels rise and fall as they should throughout the menstrual cycle. This will your luteal phase [progesterone](https://nabtahealth.com/glossary/progesterone/) levels reach 7-10ng/mL. If this does not work, your doctor may recommend that you use medication to induce [ovulation](https://nabtahealth.com/glossary/ovulation/), for example, clomiphene citrate. These medications do not work for all women; so, following treatment, Levels will be monitored to discern whether or not [ovulation](https://nabtahealth.com/glossary/ovulation/) has occurred. [Progesterone](https://nabtahealth.com/glossary/progesterone/) levels of 15ng/mL or higher indicate successful [ovulation](https://nabtahealth.com/glossary/ovulation/) induction. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#562f373a3a371638373422373e33373a223e7835393b) if you have any questions about this article or any aspect of women’s health. We’re here for you. If you have a [h](https://nabtahealth.com/im-worried-my-progesterone-levels-are-too-high/)[igh](https://nabtahealth.com/im-worried-my-progesterone-levels-are-too-high/) [progesterone](https://nabtahealth.com/glossary/progesterone/) level read the article **Sources:** * Azziz, Ricardo, et al. “The Androgen Excess and [PCOS](https://nabtahealth.com/glossary/pcos/) Society Criteria for the Polycystic Ovary Syndrome: the Complete Task Force Report.” Fertility and Sterility, vol. 91, no. 2, Feb. 2009, pp. 456–488., doi:10.1016/j.fertnstert.2008.06.035. * Holesh JE, Hazhirkarzar B, Lord M. Physiology, [Ovulation](https://nabtahealth.com/glossary/ovulation/). \[Updated 2019 Oct 19\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK441996/.](https://www.ncbi.nlm.nih.gov/books/NBK441996/) * Strauss, Jerome F., and Robert L. Barbieri. Yen & Jaffes Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management. 7th ed., Elsevier, 2014.
A normal menstrual cycle lasts between 21 and 35 days. Day one of the cycle is always the first day of menstrual bleeding (also known as having your period). Menstrual bleeding typically lasts for between 2 and 7 days and is often incorrectly used as a sign that [ovulation](https://nabtahealth.com/glossary/ovulation/) has occurred. In fact, women can have apparently normal periods without ovulating, click [here](https://nabtahealth.com/i-have-regular-periods-could-i-still-have-pcos/) to find out more. Normal [ovulation](https://nabtahealth.com/glossary/ovulation/) is essential for maintaining healthy levels of [oestrogen](https://nabtahealth.com/glossary/oestrogen/) and [progesterone](https://nabtahealth.com/glossary/progesterone/). Whilst these two hormones play a pivotal role during pregnancy, their beneficial effects are not limited to this; they are also vital for maintaining general health and help to protect against [osteoporosis](https://nabtahealth.com/glossary/osteoporosis/), breast cancer and heart disease. #### What defines abnormal uterine bleeding? Abnormal uterine bleeding affects 2-5% of women of reproductive age. It occurs when the cycle length and period duration differ from the normal values. It is a broad term that also encompasses bleeding or spotting between periods. Unfortunately this wide categorisation means that there are many potential causes of abnormal uterine bleeding and, often, diagnosis becomes a process of elimination. When abnormal uterine bleeding takes the form of prolonged, or heavy bleeding it is termed [menorrhagia](https://nabtahealth.com/glossary/menorrhagia/). Medically a ‘heavy’ period is defined as losing more than 80ml blood and/or it having a duration of over 7 days. Young teenagers and women experiencing the [perimenopause](https://nabtahealth.com/glossary/perimenopause/) are most at risk. For young teenagers it is usually just a case of their bodies settling into a regular cycle. Women who are perimenopausal are nearing the end of their reproductive years and will probably find the bleeding becomes more irregular and sporadic, before stopping altogether. Treatment options range from non-steroidal anti-inflammatory drugs, which block [prostaglandins](https://nabtahealth.com/glossary/prostaglandins/) (easing painful period cramps) and reduce menstrual flow; to hormonal treatment, such as the combined [oral contraceptive pill](https://nabtahealth.com/the-oral-contraceptive-pill/%MCEPASTEBIN%), which stabilises the endometrial lining and ensures controlled monthly bleeds. In the most severe cases a female may need to undergo a [hysterectomy](https://nabtahealth.com/glossary/hysterectomy/). Broadly speaking, abnormal uterine bleeding occurs because of structural abnormalities, lifestyle disruptions or [ovulation](https://nabtahealth.com/glossary/ovulation/) disorders. #### Structural abnormalities These can include [benign](https://nabtahealth.com/glossary/benign/) lesions such as [](../a-simple-guide-to-fibroids)[fibroids](https://nabtahealth.com/glossary/fibroids/), [](../what-are-uterine-polyps)[polyps](https://nabtahealth.com/glossary/polyps/) and [](../what-is-adenomyosis)[adenomyosis](https://nabtahealth.com/glossary/adenomyosis/), as well as lesions of the [cervix](https://nabtahealth.com/glossary/cervix/) and the [vagina](https://nabtahealth.com/glossary/vagina/). [](../what-is-endometriosis)[Endometriosis](https://nabtahealth.com/glossary/endometriosis/) is a well characterised condition that results from a build-up of endometrial-like tissue elsewhere in the body; chronic period pain and heavy periods are two of the main symptoms. Complications during the early stages of pregnancy, such as [miscarriage](https://nabtahealth.com/glossary/miscarriage/) and [](../what-is-an-ectopic-pregnancy)[ectopic pregnancy](https://nabtahealth.com/glossary/ectopic-pregnancy/) can also result in abnormal bleeding. Sometimes women who have an intrauterine device ([IUD](https://nabtahealth.com/glossary/iud/)) fitted for contraception will experience abnormal bleeding. Most structural abnormalities can be identified with ultrasound; for lesions deep within the pelvic region, a high resolution [transvaginal ultrasound](https://nabtahealth.com/glossary/transvaginal-ultrasound/) is a very useful diagnostic aid. Occasionally surgery will be required; [hysteroscopies](../what-is-a-hysteroscopy) (within the uterine cavity) and [laparoscopies](../what-is-a-laparoscopy) (outside the [uterus](https://nabtahealth.com/glossary/uterus/)) can be used for both diagnosis and ablation of unwanted lesions. #### Lifestyle disruptions Certain medications and medical conditions can disrupt the menstrual cycle. Diabetes is one example. There appears to be some association between [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and a thickening of the uterine lining, the latter of which results in heavy periods. Emotional and physical stress can cause the menstrual cycle to become irregular, as can [obesity](https://nabtahealth.com/what-is-body-mass-index-bmi/%MCEPASTEBIN%) ([BMI](https://nabtahealth.com/glossary/bmi/) >30) and smoking. These are known as modifiable risk factors because through making behavioural adjustments, the risk of experiencing menstrual irregularities is reduced. #### [Ovulation](https://nabtahealth.com/glossary/ovulation/) disorders If no other cause can be established for abnormal uterine bleeding then an [ovulation](https://nabtahealth.com/glossary/ovulation/) disorder will probably be considered. These are classed as dysfunctional uterine bleeding and the most common examples are [polycystic ovary syndrome](../treating-the-associated-symptoms-of-pcos) ([PCOS](https://nabtahealth.com/glossary/pcos/)), thyroid disease and premature ovarian insufficiency ([POI](https://nabtahealth.com/glossary/poi/)). Thyroid disease is frequently misdiagnosed as [PCOS](https://nabtahealth.com/glossary/pcos/) because it shares a number of common symptoms, including [anovulation](https://nabtahealth.com/glossary/anovulation/) and [hair loss](../coping-with-pcos-hair-loss). However, thyroid disease itself has a strong association with irregular menstrual cycles. One study found that 44% of people with menstrual disorders had an underlying thyroid issue. The predominant thyroid issue is [hypothyroidism](https://nabtahealth.com/glossary/hypothyroidism/), which suppresses [ovulation](https://nabtahealth.com/glossary/ovulation/), impairs insulin sensitivity and reduces the availability of cellular energy (ATP). Normal ovarian function requires significant energy. The advantage to finding out you have an [ovulation](https://nabtahealth.com/glossary/ovulation/) disorder is that often it is [reversible](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) with changes to the diet and lifestyle. For example, losing weight can improve the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/). [POI](https://nabtahealth.com/glossary/poi/) is one case where lifestyle modifications will unfortunately not help. It happens when the [ovaries](https://nabtahealth.com/glossary/ovaries/) stop producing eggs and can come on gradually or occur suddenly. The first sign of the condition will usually be irregular menstrual cycles. In 50% of cases the cause is unknown, although there is thought to be a familial component. This condition can also occur in women who have undergone [](https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/radiotherapy/about)[radiotherapy](https://nabtahealth.com/glossary/radiotherapy/) or [](https://nabtahealth.com/articles/skin-changes-after-chemotherapy/)[chemotherapy](https://nabtahealth.com/glossary/chemotherapy/). Symptoms can be alleviated with hormone replacement therapy, but to date there is no cure. Unfortunately doctors are often unsure how best to manage _abnormal uterine bleeding_ and treatment is, at best, random and speculative, and at worst, ineffective. It is of fundamental importance to identify the reasons for your [irregular cycles](https://nabtahealth.com/articles/why-are-my-periods-irregular/) and abnormal bleeding because only that way will you be able to find a solution that provides complete symptomatic relief. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [](https://nabtahealth.com/articles/effects-of-menopause-on-the-body/)[menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#0a736b66666b4a646b687e6b626f6b667e6224696567) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * “Abnormal Uterine Bleeding (Booklet).” ReproductiveFacts.org, The American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/abnormal-uterine-bleeding/. Revised 2012. * Ajmani, N S, et al. “Role of Thyroid Dysfunction in Patients with Menstrual Disorders in Tertiary Care Center of Walled City of Delhi.” Journal of Obstetrics and Gynaecology of India , vol. 66, no. 2, Apr. 2016, pp. 115–119., doi:10.1007/s13224-014-0650-0. * Bae, J, et al. “Factors Associated with Menstrual Cycle Irregularity and [Menopause](https://nabtahealth.com/glossary/menopause/).” BMC Women’s Health, vol. 18, no. 1, 6 Feb. 2018, p. 36., doi:10.1186/s12905-018-0528-x. * Koutras, D A. “Disturbances of Menstruation in Thyroid Disease.” Annals of the New York Academy of Sciences, vol. 816, 17 June 1997, pp. 280–284. * “Overview: Heavy Periods.” NHS, [www.nhs.uk/conditions/heavy-periods/](http://www.nhs.uk/conditions/heavy-periods/). Page last reviewed: 07/06/2018. * “What Is Premature Ovarian Insufficiency (Also Called Premature Ovarian Failure)? .” ReproductiveFacts.org, The American Society for Reproductive Medicine, [www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/what-is-premature-ovarian-insufficiency-also-called-premature-ovarian-failure/](http://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/what-is-premature-ovarian-insufficiency-also-called-premature-ovarian-failure/). Revised 2015.
\***_According to Patient Feedback_** “Who are the best gynaecologists in Dubai? Can anyone recommend an OBGYN?” You asked us and we turned the question back to you. We have compiled the top 10 gynaecologists in Dubai, based only on real patient recommendations, experience and feedback. No healthcare professionals were questioned. Gathered from exemplary recommendations across Dubai social media forums, these top 10 gynaecologists in Dubai not only have a wealth of clinical expertise in their field, they also stand out for the overwhelmingly positive comments from their patients. #### **Dr Salma Ballal, Consultant Obstetrics and Gynaecology, [Genesis Healthcare Center](https://www.genesis-dubai.com/our_doctors/dr-salma-ballal/)** Having delivered well over 1000 babies, Dr Salma Ballal has extensive experience in managing normal and complex pregnancies and deliveries. Dr Salma trained in obstetrics and gynaecology with the UK’s NHS where she developed a strong interest in maternal medicine, high-risk pregnancies, and labour care. She completed advanced maternal medicine and labour ward practice training with the Royal College of Obstetrics and Gynaecology (RCOG) before moving to Dubai in 2014. Dr Salma was most recently at Mediclinic Parkview hospital before joining the Genesis Healthcare Center team. Dr Salma believes in open communication with her patients and that “women should be kept informed through every step of what is the most amazing experience in any woman’s life.” She also offers pre-pregnancy counselling to patients with complicated or traumatic pregnancy history. Patients describe Dr Salma as “refreshingly honest”, and “very safe hands”, saying she “totally respected my wishes”. #### **Dr Esra Majid, Consultant [Obstetrician](https://nabtahealth.com/glossary/obstetrician/) and [Gynaecologist](https://nabtahealth.com/glossary/gynaecologist/),** [**Kings’ College Hospital Dubai**](https://kingscollegehospitaldubai.com/dr/esra-mejid/) Based in Dubai since 2016, Dr Esra has built a reputation for her management of high-risk pregnancies and gynaecological conditions. She worked at Al Zahra Hospital Dubai, where she regularly received excellent feedback from her patients, before moving to King’s College Hospital Dubai. At Kings’ College Hospital Dubai Dr Esra “performs major surgical procedures, follow up of high-risk pregnancies and deliveries, along with natural and water births.” Dr Esra qualified in Baghdad and went on to complete her Board Certificate in Obstetrics and Gynaecology in Sweden. She worked at the teaching hospital Sundsvall County Hospital and as a specialist at Sodra Alv Bord Hospital in Gothenburg before moving to Dubai. Patients have praised Dr Esra for her expertise and skill, describing her as “straight to the point, warm and approachable.” #### **Dr Vibha Sharma, Specialist [Gynaecologist](https://nabtahealth.com/glossary/gynaecologist/),** [**Prime Medical Center**](https://www.primehealth.ae/prime-medical-centers/medical-centers/prime-medical-center-sheikh-zayed-road/dr-vibha-sharma) Working in Dubai since 2004, Dr Vibha is known for her commitment to supporting women with a range of gynaecological and women’s health problems. In the UAE she worked at Ministry of Health and Tertiary Care hospitals prior to joining Prime Medical Center. Dr Vibha specialises in areas of women’s health requiring specialist gynaecological expertise. Qualified in India at Jammu Medical College, Dr Vibha went on to do her post-graduate at King George’s Medical College in Lucknow. She worked at Queen Mary’s Hospital Lucknow and Willingdon and Batra Hospitals and Research Centre in New Delhi before moving to the Middle East. Patients have described Dr Vibha as “consistent”, “approachable”, and “professional”. **Dr Aisha Alzouebi, Consultant [Obstetrician](https://nabtahealth.com/glossary/obstetrician/) and [Gynaecologist](https://nabtahealth.com/glossary/gynaecologist/),** [**Mediclinic Parkview Hospital**](https://www.mediclinic.ae/en/corporate/doctors/1/aisha-alzouebi-dr.html) Dr Aisha Alzouebi has more than 15 years of experience in obstetrics and gynaecology in the UK and the UAE, with specialist expertise in “early pregnancy, management of complications in early pregnancy, family planning and sexual health, [benign](https://nabtahealth.com/glossary/benign/) open and laparoscopic surgery and hysteroscopy.” A member of the UK’s Royal College of Obstetricians and Gynaecologists (RCOG), Dr Aisha attended medical school at Sheffield University and completed her Masters in Surgical Education at Imperial College London. Patient social media feedback on Dr Aisha said, “she was brilliant”, “I would highly recommend her”, “Dr Aisha is great”. #### **Dr Reeja Mary Abraham, Specialist in Obstetrics and Gynaecology,** [**Medcare Women and Children Hospital**](https://www.medcare.ae/en/physician/view/reeja-mary-abraham.html) A specialist in high-risk pregnancies, Dr Reeja takes an “evidence-based” approach to complex and low risk gynaecological issues. Dr Reeja is based at Medcare Women and Children Hospital, where she also “performs and assists in major and minor gynaecological procedures”. A member of the Indian Medical Association (IMA) and the Kerala Federation of Obstetricians and Gynaecologists (KFOG), Dr Reeja began her medical career at Christian Fellowship Hospital in Oddanchatram, Tamil Nadu and worked in hospitals in Kerala and Tamil Nadu before moving to Dubai to work at Medcare Women and Children Hospital. Patients recommending Dr Reeja describe her as “kind and attentive”, “highly professional”, and “detail-oriented”. #### **Dr Nashwa Abulhassan, Head of Obstetrics and Gynaecology, Dr** [**Sulaiman Al Habib Hospital Healthcare City**](https://www.hmguae.com/doctor/dr-nashwa-abul-hassan/) Dr Nashwa is a specialist in normal and complex pregnancies and deliveries, as well as “acute gynaecology and early pregnancy complications management” based at Dr Sulaiman Al Habib Hospital Healthcare City. A member of the Royal College of Obstetricians and Gynaecologists (RCOG) and an accredited member of the British society of colposcopists and cervical pathologists, Dr Nashwa has more than 15 years of experience in the UK and the UAE. Dr Nashwa has been featured in the UAE media discussing pregnancy complications and was most recently in [Gulf News](https://gulfnews.com/uae/health/step-by-step-guide-to-dealing-with-covid-19-during-pregnancy-1.80112211), offering advice for pregnant women who have tested positive for Covid-19. Dr Nashwa’s patients describe her as “kind and caring”. #### **Dr Samina Dornan, Consultant [Obstetrician](https://nabtahealth.com/glossary/obstetrician/) and [Gynaecologist](https://nabtahealth.com/glossary/gynaecologist/) and sub specialist in Maternal Fetal Medicine, [Al Zahra Hospital](https://azhd.ae/doctors/dr-samina-dornan/#:~:text=Consultant%20Maternal%20and%20Fetal%20Medicine,London%20to%20come%20to%20Dubai.)** An established international voice on maternal and fetal health issues, Dr Samina Dornan has extensive experience in fetal medicine. At Al Zahra Hospital she works as a consultant [obstetrician](https://nabtahealth.com/glossary/obstetrician/) and gynecologist with a sub-specialty in Maternal Fetal Medicine. Dr Samina qualified at Queen’s University Belfast. She received a fellowship from the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 and is the “first female Maternal Fetal Medicine sub-specialist \[at RCOG\]” to work with patients in Dubai. Frequently quoted in the media, Dr Samina is “extensively published in complex twin pregnancies”. Patient feedback on Dr Samina is overwhelmingly positive, describing her as “wonderful”, “absolutely fantastic”, “caring” and “amazing”. #### **Dr Sarah Francis, Consultant Obstetrics and Gynaecology,** [**American Hospital Dubai and American Hospital Al Khawaneej Clinic**](https://www.ahdubai.com/doctors-profile/sarah-francis) With clinical expertise in general and [benign](https://nabtahealth.com/glossary/benign/) gynaecology, adolescent gynaecological issues, polycystic ovarian syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)), and low and high-risk pregnancies, Dr Sarah supports patients at American Hospital Dubai and American Hospital Al Khawaneej Clinic. A member of the Royal College of Obstetricians and Gynaecologists (RCOG), Dr Sarah qualified in Sierra Leone and practised in NHS hospitals and trusts across the UK before moving to the UAE. She worked with patients at Drs Nicholas and Asp clinics before joining the team at American Hospital. Patients say that Dr Sarah is “wonderful” and “exceptionally supportive”. #### **Dr Dragana Pavlovic-Acimovic, Specialist Obstetrics and Gynaecology,** [**Mediclinic Meadows**](https://www.mediclinic.ae/en/corporate/doctors/8/dragana-pavlovic-acimovic.html) Dr Dragana has “a special interest in obstetrics” and consults on “adolescent gynaecology, [menopause](https://nabtahealth.com/glossary/menopause/), family planning” and various gynaecological conditions. Dr Dragana qualified in Serbia and started her career at University Hospital Narodni Front in Belgrade, “the largest specialised obstetrics and gynaecology centre in South-East Europe”. She moved to Dubai in 2015 and worked at Drs Nicholas and Asp before joining Mediclinic. Patients’ experience with Dr Dragana is “great”. #### **Dr Alessandra Pipan, Consultant [Obstetrician](https://nabtahealth.com/glossary/obstetrician/) and [Gynaecologist](https://nabtahealth.com/glossary/gynaecologist/),** [**Mediclinic City Hospital**](https://www.mediclinic.ae/en/corporate/doctors/1/alessandra-pipan.html) With more than 30 years’ experience in gynaecology and obstetrics Dr Alessandra treats a range of gynaecological conditions, is a specialist in [infertility](https://nabtahealth.com/glossary/infertility/) and oncology, and works with high-risk pregnancies at Mediclinic City Hospital. A member of the Royal College of Obstetrics and Gynaecology (RCOG), the European Society of Reproduction and Embryology, and the European Society of Gynaecological Endoscopy, Dr Alessandra qualified at Cattolica University of Rome, Italy and has developed extensive sector experience in positions across the Italian and UAE healthcare institutions. Patients of Dr Alessandra have described her as “great” and “amazing”. \_\_\_ Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [](https://nabtahealth.com/glossary)[menopause](https://nabtahealth.com/glossary/menopause/). You can track your menstrual cycle and get [personalised support by using the Nabta app.](https://nabtahealth.com/our-platform/nabta-app/) Get in [touch](/cdn-cgi/l/email-protection#fc859d90909dbc929d9e889d94999d908894d29f9391) if you have any questions about this article or any aspect of women’s health. We’re here for you.
[PCOS](https://nabtahealth.com/glossary/pcos/) is the most common hormonal condition to affect women of reproductive age. It can have a detrimental effect on fertility, as women with the condition [struggle to conceive](https://nabtahealth.com/pcos-and-pregnancy/) and are at greater risk of experiencing pregnancy complications, including [miscarriage](https://nabtahealth.com/glossary/miscarriage/). It is also thought that [PCOS](https://nabtahealth.com/glossary/pcos/) can affect a female’s ability to breastfeed, with some studies showing that women with clinically diagnosed [PCOS](https://nabtahealth.com/glossary/pcos/) are less likely to commence breastfeeding than those who do not have the condition. The issue seems to be with initiation of breastfeeding, as once it is successfully established, women with [PCOS](https://nabtahealth.com/glossary/pcos/) are no more likely to stop breastfeeding than their counterparts. If you have [PCOS](https://nabtahealth.com/glossary/pcos/) and are having difficulty establishing breastfeeding there are steps you can take to make the process easier. The [advantages of breastfeeding](https://nabtahealth.com/benefits-of-breastfeeding/) for both mother and child, are extensive and far-reaching; benefiting the child’s health for the foreseeable future, and, as such, support should be given to all women who are finding the process challenging. #### **Reasons why [PCOS](https://nabtahealth.com/glossary/pcos/) might make breastfeeding more challenging** Women with [PCOS](https://nabtahealth.com/glossary/pcos/) often have lower levels of [progesterone](https://nabtahealth.com/glossary/progesterone/), particularly if they do not ovulate regularly. [Anovulation](https://nabtahealth.com/glossary/anovulation/) is one of the main [clinical symptoms of](https://nabtahealth.com/what-is-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/). [Progesterone](https://nabtahealth.com/glossary/progesterone/) is required for normal breast development. It has been suggested that women with [PCOS](https://nabtahealth.com/glossary/pcos/) have insufficient glandular breast tissue, meaning that the breasts cannot undergo the normal physiological changes necessary during pregnancy. Women with [PCOS](https://nabtahealth.com/glossary/pcos/) are often hyperandrogenic, meaning they produce high levels of [androgens](https://nabtahealth.com/glossary/androgen/). Specifically, levels of Dehydroepiandrosterone‐sulphate (DHEAS) have been shown to be elevated in pregnant women with [PCOS](https://nabtahealth.com/glossary/pcos/). DHEAS is a weak androgen, however, it can undergo conversion to more potent [androgens](https://nabtahealth.com/glossary/androgen/), including [testosterone](https://nabtahealth.com/glossary/testosterone/). One of the sites for this conversion is the mammary glands, which suggests a potential build-up of [testosterone](https://nabtahealth.com/glossary/testosterone/) in the breast tissue of women with [PCOS](https://nabtahealth.com/glossary/pcos/) during pregnancy. [Androgens](https://nabtahealth.com/glossary/androgen/) suppress [prolactin](https://nabtahealth.com/glossary/prolactin/) receptors and inhibit [lactation](https://nabtahealth.com/glossary/lactation/). [Prolactin](https://nabtahealth.com/glossary/prolactin/) is essential for breast growth and milk synthesis. [Prolactin](https://nabtahealth.com/glossary/prolactin/) efficiency can also be compromised by high insulin levels. [](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/)[Insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) is a common symptom of [PCOS](https://nabtahealth.com/glossary/pcos/) and many women with the condition have higher than normal levels of circulating insulin. Aside from having a direct effect on milk synthesis through the proliferation of mammary gland cells, insulin also contributes to the high androgen levels seen in women with [PCOS](https://nabtahealth.com/glossary/pcos/). #### **The counterargument** One large cohort investigation looking at almost 5000 women, of whom 6.5% had [PCOS](https://nabtahealth.com/glossary/pcos/), identified that there was a positive association between obesity and breastfeeding. Obese mothers were less likely to initiate and subsequently persevere with breastfeeding. Many of the women with [PCOS](https://nabtahealth.com/glossary/pcos/) were overweight, but any [lactation](https://nabtahealth.com/glossary/lactation/) issues were attributed to them having a high [](https://nabtahealth.com/what-is-body-mass-index-bmi/)[BMI](https://nabtahealth.com/glossary/bmi/), rather than their [PCOS](https://nabtahealth.com/glossary/pcos/) status. Certainly there are explanations for why obesity may be linked to lower breastfeeding rates. Women who are obese are more likely to require interventions during labour and delivery, which lowers the likelihood of them breastfeeding. They may experience mechanical difficulties with the baby latching due to their increased size. Obesity is also a driving factor for [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) and [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/), and, as described above, these are two of the proposed causes of low breastfeeding rates and/or [lactation](https://nabtahealth.com/glossary/lactation/) difficulties. Thus, it remains unclear whether women with [PCOS](https://nabtahealth.com/glossary/pcos/) struggle to breastfeed because of their condition, or because of their associated symptoms. Furthermore, it must be considered that for some women breastfeeding is challenging. This may be entirely irrespective of any coexisting medical conditions. Perhaps the reason why breastfeeding is difficult does not really matter and we should instead look for solutions to the problem. #### **Why it is important** The [World Health Organisation](https://www.who.int/nutrition/publications/globaltargets2025_policybrief_overview/en/) recommends that all babies are exclusively breastfed for the first six months of life. Breastfeeding is singularly the best way of satisfying all your baby’s nutritional needs and should be a resource that is freely available and accessible for all. It is for these reasons that all women who are struggling to breastfeed should be given sufficient help and support to overcome the barriers they face, whether these are medical, physical, emotional or a combination of the three. Such support might include, speaking to a [lactation](https://nabtahealth.com/glossary/lactation/) specialist, as well as taking pharmacological or herbal supplements (galactogogues) to help. For a detailed summary of these approaches, click [here](https://nabtahealth.com/3-ways-to-boost-milk-supply/). Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#d5acb4b9b9b495bbb4b7a1b4bdb0b4b9a1bdfbb6bab8) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Joham, Anju E., et al. “Obesity, Polycystic Ovary Syndrome and Breastfeeding: an Observational Study.” Acta Obstetricia Et Gynecologica Scandinavica, vol. 95, no. 4, 18 Jan. 2016, pp. 458–466., doi:10.1111/aogs.12850. * Kochenour, N K. “[Lactation](https://nabtahealth.com/glossary/lactation/) Suppression.” Clinical Obstetrics and Gynecology, vol. 23, no. 4, Dec. 1980, pp. 1045–1059., doi:10.1097/00003081-198012000-00008. * Marasco, Lisa, et al. “Polycystic Ovary Syndrome: A Connection to Insufficient Milk Supply?” Journal of Human [Lactation](https://nabtahealth.com/glossary/lactation/), vol. 16, no. 2, May 2000, pp. 143–148., doi:10.1177/089033440001600211. * Sir-Petermann, T., et al. “Maternal Serum [Androgens](https://nabtahealth.com/glossary/androgen/) in Pregnant Women with Polycystic Ovarian Syndrome: Possible Implications in Prenatal Androgenization.” Human Reproduction, vol. 17, no. 10, Oct. 2002, pp. 2573–2579., doi:10.1093/humrep/17.10.2573.
Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is most frequently classified according to the predominant clinical symptoms that a patient presents with. The three major ones are [anovulation](https://nabtahealth.com/glossary/anovulation/), [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) and polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/); and most medical guidelines stipulate that two out of three of these are required prior to a diagnosis being made. You can read more about how the condition is classified by symptoms by clicking [here](https://nabtahealth.com/what-is-pcos/). Of course discerning the type of [PCOS](https://nabtahealth.com/glossary/pcos/) that you have is very important. Only by understanding this will you be able to instigate a treatment plan. However, to really treat the condition and to achieve optimal relief from the symptoms you have, it is perhaps worth breaking it down further and looking at the factors that are very closely associated with [PCOS](https://nabtahealth.com/glossary/pcos/). There is substantial evidence that by managing these factors and alleviating the associated symptoms, you will significantly reduce the impact [PCOS](https://nabtahealth.com/glossary/pcos/) has on your day-to-day life. #### **[Insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/)** An increased sensitivity to insulin is very common in women who have classic [PCOS](https://nabtahealth.com/glossary/pcos/). Classic [PCOS](https://nabtahealth.com/glossary/pcos/) is characterised by **chronic [anovulation](https://nabtahealth.com/glossary/anovulation/) and [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/)** with or without polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/). Women with classic [PCOS](https://nabtahealth.com/glossary/pcos/) are more likely to experience concurrent metabolic symptoms, the most common of which is [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). Up to 85% of patients with [PCOS](https://nabtahealth.com/glossary/pcos/) have [hyperinsulinemia](https://nabtahealth.com/glossary/hyperinsulinemia/). These patients are often borderline diabetic and are frequently overweight. Increased insulin potentiates ovarian androgen production, which is a driving factor of [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). Insulin modulates ovarian steroidogenesis, which is the process by which the steroid hormones oestradiol and [progesterone](https://nabtahealth.com/glossary/progesterone/) are synthesised from [cholesterol](https://nabtahealth.com/glossary/cholesterol/). It is also involved in the control of [ovulation](https://nabtahealth.com/glossary/ovulation/), via an insulin signalling pathway in the central nervous system. #### **Treating [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/)** [Insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) is often treated with insulin sensitising drugs, such as [metformin](https://nabtahealth.com/what-is-metformin/). Whilst this type of medication does not completely normalise circulating androgen levels, it can significantly reduce [testosterone](https://nabtahealth.com/glossary/testosterone/) levels and has been used to successfully restore ovulatory menstrual cycles in some women with classic [PCOS](https://nabtahealth.com/glossary/pcos/). Another frequently prescribed medication for the treatment of [PCOS](https://nabtahealth.com/glossary/pcos/) is the [oral contraceptive pill](https://nabtahealth.com/the-oral-contraceptive-pill/). This treatment is **not suitable for those who are insulin resistant**, as many forms of the pill impair insulin sensitivity. This means that, worryingly, the most widely used treatment for [PCOS](https://nabtahealth.com/glossary/pcos/) is probably unsuitable for the majority of women who exhibit the symptoms of the classic form of the condition. This should be [discussed with your doctor](https://nabtahealth.com/five-things-your-doctor-probably-wont-tell-you-about-pcos/) prior to commencing treatment. Fortunately, there is an alternative, which avoids prolonged use of medication (that may be doing more harm than good anyway). **Lifestyle modifications** in the form of diet adjustments, weight loss and reduced sugar intake, can help to rectify the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/) that are associated with [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). Studies have shown that as little as 5% weight loss can regulate the menstrual cycle and improve fertility. In fact, holistic lifestyle changes are now considered to be the most sustainable treatment approach for many patients with [PCOS](https://nabtahealth.com/glossary/pcos/). Alongside this, dietary supplements can be used to provide complementary relief from the symptoms of classic [PCOS](https://nabtahealth.com/glossary/pcos/). Oral magnesium supplements have been shown to improve insulin sensitivity, and small-scale studies have demonstrated that co-supplementation of omega-3 fatty acids with [vitamin E](https://nabtahealth.com/glossary/vitamin-e/) improved [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and reduced the levels of circulating [testosterone](https://nabtahealth.com/glossary/testosterone/). Further work is required to substantiate the claim that omega-3 fatty acids may be a viable treatment option for [PCOS](https://nabtahealth.com/glossary/pcos/). Women who have [PCOS](https://nabtahealth.com/glossary/pcos/) and are insulin resistant need to find a way of **managing their condition**, not just for short term symptomatic relief, but also because they are predisposed to developing other conditions including metabolic syndrome, non-alcoholic fatty liver disease, [](https://nabtahealth.com/gestational-diabetes-8-things-you-should-know/)[gestational diabetes](https://nabtahealth.com/glossary/gestational-diabetes/) and pregnancy-induced [hypertension](https://nabtahealth.com/glossary/hypertension/). Finally, women with non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) who have normal [ovulation](https://nabtahealth.com/glossary/ovulation/) and/or normal androgen levels, will usually only experience mild metabolic symptoms. They are less likely to be overweight and will often have normal insulin sensitivity. However, there is the possibility that extrinsic risk factors, such as weight gain, may cause their condition to convert to classic [PCOS](https://nabtahealth.com/glossary/pcos/) over time. Thus, a good diet and maintenance of a healthy weight is recommended for all women with [PCOS](https://nabtahealth.com/glossary/pcos/). #### **Obesity and [Inflammation](https://nabtahealth.com/glossary/inflammation/)** Obesity is a common side effect of classic [PCOS](https://nabtahealth.com/glossary/pcos/); between 50 and 80% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) are obese ([Body Mass Index](https://nabtahealth.com/what-is-body-mass-index-bmi/) ([BMI](https://nabtahealth.com/glossary/bmi/)) > 25). Women who are obese also seem to have more severe signs of [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). Obesity is intrinsically linked to [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/), and furthermore, being overweight serves as a maker of **chronic low-grade [inflammation](https://nabtahealth.com/glossary/inflammation/)**. [Inflammation](https://nabtahealth.com/glossary/inflammation/) is inherently linked to almost all diseases. Exposure to any stressor or inflammatory agent, whether it is endogenous, or an external trigger in the diet or environment, causes the immune system to react and produce certain markers. Measuring the levels of these markers can help to determine the inflammatory status of a particular individual. Whilst it is widely accepted that [PCOS](https://nabtahealth.com/glossary/pcos/) is a condition of chronic low-grade [inflammation](https://nabtahealth.com/glossary/inflammation/), controversy remains as to whether the condition itself is inflammatory, or whether the circulating markers that are found in the blood serum are a secondary effect of the associated conditions, such as [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and obesity. One meta-analysis (a review encompassing a large number of studies) found a two-fold elevation in one of the most common [inflammation](https://nabtahealth.com/glossary/inflammation/) markers, C-reactive protein, in women with classic [PCOS](https://nabtahealth.com/glossary/pcos/). This increase was independent of obesity status. Other studies have found increases in the levels of interleukin-18 and higher white blood cell counts, which are both markers of [inflammation](https://nabtahealth.com/glossary/inflammation/). However, critics of the theory argue that the fold changes are not large, often the study sizes are small, and the results are inconsistent. It should also be noted that reproductive processes including [ovulation](https://nabtahealth.com/glossary/ovulation/) and menstruation, cause a transient increase in markers of [inflammation](https://nabtahealth.com/glossary/inflammation/), but, under normal conditions, these inflammatory reactions are rapidly resolved and normal reproductive function is maintained. There is some evidence that [inflammation](https://nabtahealth.com/glossary/inflammation/) can impede [ovulation](https://nabtahealth.com/glossary/ovulation/) directly and that it stimulates the [ovaries](https://nabtahealth.com/glossary/ovaries/) to produce excess [androgens](https://nabtahealth.com/glossary/androgen/). This would indicate that [chronic inflammation](https://nabtahealth.com/glossary/chronic-inflammation/) is the driving factor behind cases of classic [PCOS](https://nabtahealth.com/glossary/pcos/); inducing the two main symptoms of the condition, [anovulation](https://nabtahealth.com/glossary/anovulation/) and [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). However, others believe that the [inflammation](https://nabtahealth.com/glossary/inflammation/) observed in women with [PCOS](https://nabtahealth.com/glossary/pcos/) is a secondary event. Regardless of the exact mechanism involved and whether the inflammatory response in [PCOS](https://nabtahealth.com/glossary/pcos/) is cause or effect, what is clear is that the **normal endocrine-immune state is disrupted** and treatment should focus on restoring it to normal. #### **Treating obesity** The first step for most women with classic [PCOS](https://nabtahealth.com/glossary/pcos/) should be to focus on **reducing their [BMI](https://nabtahealth.com/glossary/bmi/)**. Losing weight reduces [inflammation](https://nabtahealth.com/glossary/inflammation/). It is also associated with a reduction in circulating [androgens](https://nabtahealth.com/glossary/androgen/), enhanced [ovulation](https://nabtahealth.com/glossary/ovulation/) induction and improvements in metabolic function. Highlighting the importance of weight loss for overcoming the symptoms of classic [PCOS](https://nabtahealth.com/glossary/pcos/). Taking a holistic approach to therapy and minimising exposure to irritants in the environment and diet also helps to alleviate some of the associated [inflammation](https://nabtahealth.com/glossary/inflammation/) seen in many cases of [PCOS](https://nabtahealth.com/glossary/pcos/). * A [healthy diet](https://nabtahealth.com/how-poor-diet-has-become-a-bigger-killer-than-smoking/) with no processed foods and limited alcohol intake will minimise the likelihood of an immune response. * Dietary supplements can also help to reduce the effects of [inflammation](https://nabtahealth.com/glossary/inflammation/). Magnesium, in addition to reducing insulin levels, has anti-inflammatory activity and, therefore, is one of the most useful supplements to take. When given as a co-supplement with [vitamin E](https://nabtahealth.com/glossary/vitamin-e/), magnesium reduced the levels of inflammatory biomarkers, including C-reactive protein, and lessened the signs of [](https://nabtahealth.com/how-to-manage-facial-hair/)[hirsutism](https://nabtahealth.com/glossary/hirsutism/). These approaches are particularly effective for patients who show other signs of immune dysfunction, such as headaches, frequent infections and skin complaints. As with [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/), there is a pressing need to manage [inflammation](https://nabtahealth.com/glossary/inflammation/) because it too can have long term health implications. If left untreated, it can predispose an individual to life-threatening conditions, such as cardiovascular disease (CVD). In fact, the [inflammation](https://nabtahealth.com/glossary/inflammation/) marker that has been shown to be increased in women with [PCOS](https://nabtahealth.com/glossary/pcos/), C-reactive protein, is regularly used as a [biomarker](https://nabtahealth.com/glossary/biomarker/) for assessing the risk of CVD. #### **Urinary and Bowel Issues** Despite its name, polycystic ovary syndrome [does not require the presence of polycystic](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/) [ovaries](https://nabtahealth.com/glossary/ovaries/). In fact, when present together, [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) and [anovulation](https://nabtahealth.com/glossary/anovulation/) comprise the classic form of [PCOS](https://nabtahealth.com/glossary/pcos/), which is more common and generally associated with more severe side effects than the non-classic form. Women who have non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) have polycystic [ovaries](https://nabtahealth.com/glossary/ovaries/) with regular menstrual cycles and [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (non-classic ovulatory [PCOS](https://nabtahealth.com/glossary/pcos/)) or normal [androgens](https://nabtahealth.com/glossary/androgen/) and chronic [anovulation](https://nabtahealth.com/glossary/anovulation/) (non-classic mild/normoandrogenic [PCOS](https://nabtahealth.com/glossary/pcos/)). Although non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) is typically milder, those women who have extensive ovarian cysts may experience pain in the pelvic region where the cysts press against the bladder and rectum. Associated symptoms include nausea, urinary conditions and [constipation](https://nabtahealth.com/glossary/constipation/). Depending on the severity of the symptoms, treatment options range from over-the-counter pain relief medication, to cyst removal under general anaesthetic. Ultrasound investigation will be used to establish how invasive the cysts are. #### **Conclusion** It is only when you start to explore the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/) in detail that the complexity of the condition becomes apparent. Clearly many of the associated factors are interlinked, for example, obesity connects both [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and [inflammation](https://nabtahealth.com/glossary/inflammation/). Many patients with [PCOS](https://nabtahealth.com/glossary/pcos/) experience symptoms that are often associated with diabetes, such as sugar cravings, frequent urination, blurred vision, delayed healing and a tingling sensation. They are also more susceptible to mood swings, anxiety and depressive episodes. However, with so many associated symptoms, the aetiology of these psychological issues is likely to be multifarious and complicated. Women who are experiencing [PCOS](https://nabtahealth.com/glossary/pcos/)\-like symptoms also need to establish whether they are due to an [underlying medical issue or a sign of pill-withdrawal](https://nabtahealth.com/transient-pcos-like-symptoms) rather than [PCOS](https://nabtahealth.com/glossary/pcos/) itself. There are a number of conditions that can give rise to [abnormal uterine bleeding](https://nabtahealth.com/what-is-abnormal-uterine-bleeding/), or [anovulation](https://nabtahealth.com/glossary/anovulation/), and [these should be discounted](https://nabtahealth.com/problems-with-traditional-diagnosis-of-pcos/) before a [PCOS](https://nabtahealth.com/glossary/pcos/) diagnosis is made. Currently, one of the major unanswered questions with regards to [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms and the associated factors is which came first? Does having [PCOS](https://nabtahealth.com/glossary/pcos/) predispose a female to becoming prediabetic, or does [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or obesity cause the symptoms characteristic of classic [PCOS](https://nabtahealth.com/glossary/pcos/) ([anovulation](https://nabtahealth.com/glossary/anovulation/) and [hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/))? There is certainly a correlation between the two and treating the [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) and losing weight seems to alleviate [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms. Try Nabta’s [](https://nabtahealth.com/product/pcos-test/)[PCOS](https://nabtahealth.com/glossary/pcos/) Test and get to learn more. To date, the best approach we have for [reversing](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/) is to uncover the associated conditions and, regardless of whether they are causative or consequential, attempt to rectify them. In doing this, it is hoped that the majority of patients will experience substantial symptomatic relief. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#8af3ebe6e6ebcae4ebe8feebe2efebe6fee2a4e9e5e7) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Diamanti-Kandarakis , E, and A Dunaif. “[Insulin Resistance](https://nabtahealth.com/glossary/insulin-resistance/) and the Polycystic Ovary Syndrome Revisited: An Update on Mechanisms and Implications.” _Endocrine Reviews_, vol. 33, no. 6, 1 Dec. 2012, pp. 981–1030., doi:10.1210/er.2011-1034. * Duleba, A J, and A Dokras. “Is [PCOS](https://nabtahealth.com/glossary/pcos/) an Inflammatory Process?” _Fertility and Sterility_, vol. 97, no. 1, Jan. 2012, pp. 7–12., doi:10.1016/j.fertnstert.2011.11.023. * Ebrahimi, F A, et al. “The Effects of Omega-3 Fatty Acids and [Vitamin E](https://nabtahealth.com/glossary/vitamin-e/) Co-Supplementation on Indices of [Insulin Resistance](https://nabtahealth.com/glossary/insulin-resistance/) and Hormonal Parameters in Patients with Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial.” _Experimental and Clinical Endocrinology & Diabetes_ , vol. 125, no. 6, June 2017, pp. 353–359., doi:10.1055/s-0042-117773. * El Hayak, S, et al. “Poly Cystic Ovarian Syndrome: An Updated Overview.” _Frontiers in Physiology_, vol. 7, 5 Apr. 2016, p. 124., doi:10.3389/fphys.2016.00124. * Escobar-Morreale, H F, et al. “Circulating Inflammatory Markers in Polycystic Ovary Syndrome: a Systematic Review and Metaanalysis.” _Fertility and Sterility_, vol. 95, no. 3, 1 Mar. 2011, pp. 1048–1058., doi:10.1016/j.fertnstert.2010.11.036. * González, F. “[Inflammation](https://nabtahealth.com/glossary/inflammation/) in Polycystic Ovary Syndrome: Underpinning of [Insulin Resistance](https://nabtahealth.com/glossary/insulin-resistance/) and Ovarian Dysfunction.” _Steroids_, vol. 77, no. 4, 10 Mar. 2012, pp. 300–305., doi:10.1016/j.steroids.2011.12.003. * Jabbour, H N, et al. “Inflammatory Pathways in Female Reproductive Health and Disease.” _Reproduction_, vol. 138, no. 6, Dec. 2009, pp. 903–919., doi:10.1530/REP-09-0247. * Lorenz, T K, et al. “Links among [Inflammation](https://nabtahealth.com/glossary/inflammation/), Sexual Activity and [Ovulation](https://nabtahealth.com/glossary/ovulation/): Evolutionary Trade-Offs and Clinical Implications.” _Evolution, Medicine and Public Health_, vol. 2015, no. 1, 16 Dec. 2015, pp. 304–324., doi:10.1093/emph/eov029. * Marshall, J C, and A Dunaif. “Should All Women with [PCOS](https://nabtahealth.com/glossary/pcos/) Be Treated for [Insulin Resistance](https://nabtahealth.com/glossary/insulin-resistance/)?” _Fertility and Sterility_, vol. 97, no. 1, Jan. 2012, pp. 18–22., doi:10.1016/j.fertnstert.2011.11.036. * Norman, R J, et al. “The Role of Lifestyle Modification in Polycystic Ovary Syndrome.” _Trends in Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/)_, vol. 13, no. 6, Aug. 2002, pp. 251–257. * Pasquali, R, et al. “The Impact of Obesity on Reproduction in Women with Polycystic Ovary Syndrome.” _BJOG_, vol. 113, no. 10, Oct. 2006, pp. 1148–1159., doi:10.1111/j.1471-0528.2006.00990.x. * Patel, S. “Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)), an Inflammatory, Systemic, Lifestyle Endocrinopathy.” _The Journal of Steroid Biochemistry and Molecular Biology_, vol. 182, Sept. 2018, pp. 27–36., doi:10.1016/j.jsbmb.2018.04.008. * Shokrpou, M, and Z Asemi. “The Effects of Magnesium and [Vitamin E](https://nabtahealth.com/glossary/vitamin-e/) Co-Supplementation on Hormonal Status and Biomarkers of [Inflammation](https://nabtahealth.com/glossary/inflammation/) and Oxidative Stress in Women with Polycystic Ovary Syndrome.” _Biological Trace Element Research_, 18 Dec. 2018, doi:doi: 10.1007/s12011-018-1602-9.
