Empowering Minds: Understanding PCOS and Prioritizing Mental Health

Written By: Kashvi Magan (2nd Year) Department Of Applied Psychology

One day a young girl approaching womanhood misses her period and she does not take it seriously but a few days later when she does have her period, she experiences intense cramps, nausea, acne and a period she has never had before. It scares her, she visits a gynecologist who asks her to get an ultrasound, PCOS panel, thyroid, lipid profile and fasting sugar tests. Based on this, the doctor gives her a diagnosis of PCOS and writes down the only cure “birth control” on the prescription. If you were diagnosed with PCOS this story will be familiar to you. According to the World Health Organisation, Polycystic Ovarian Syndrome (PCOS) affects an estimated 8–13% of reproductive-aged women, which is approximately 1 in every 5 women and up to 70% of affected women remain undiagnosed worldwide. Polycystic ovarian syndrome (PCOS) or polycystic ovarian disorder (PCOD) is a hormonal condition that causes an increased production of androgens, anovulation and insulin. This disrupts the normal functioning of reproductive hormones in a woman, which may cause irregular or missed periods, acne, infertility, excess hair growth on the body or male patterns of hair growth.

See, the agenda of the article is simple, for every woman and every little girl to have the opportunity to know their body and make informed decisions relating to it. At my core, I hope this article achieves the aim of making every woman aware of the knowledge that has been kept hidden from them for so long. Initially, I will go on creating a technical base, I will discuss the causes and social implications of PCOS, as well as, my personal experience with it and what it helped me learn.

Biological rhythms, also known as biological clocks, do not only relate to one’s ideal age of conception, rather these are internal clocks that manage the body’s natural cycle of change in chemicals and functions. These rhythms are controlled by the Suprachiasmatic Nucleus (SCN) in the hypothalamus which controls the autonomic nervous system and the pituitary gland. The hypothalamus and pituitary gland are responsible for the release of hormones in the body and the regulation of bodily activities like heart rate, blood volume, urination, reproductive organs etc. The main agenda of these biological rhythms is to maintain the homeostasis state of the body to ensure optimal functioning and well-being, and disruption of this rhythm can be a host to a lot of problems, which is also referred to as “modern issues'' or “lifestyle problems” in today’s stressful world. Biological rhythms are mainly of two types-

• Circadian Rhythms: The circadian rhythm is the built-in, naturally occurring, approximately 24-hour cycle, also known as the sleep-wake cycle, that functions according to the sunrise and the sunset. When the sun rises, the suprachiasmatic nucleus (SCN), which is a bunch of specialized neurons in the hypothalamus, receives the neural messages via optic nerve signals that activate the endocrine system of the body. The adrenal glands start releasing cortisol, which makes the body more alert, raises body temperature, starts digestive activity and is a cue for various other hormonal activities in the body. Whereas when the sun starts setting down, the SCN signals the pineal gland to release melatonin, which induces sleep and the body is geared into a resting and repair mode, bringing down the body temperature and digestive function. In the modern world, with access to fluorescent lights and gadgets, different work shifts, stress, diet including sugary and caffeinated drinks as well as traveling to different time zones for work, this sleep-wake cycle has been hampered. Unlimited access to light often leaves the brain confused about what time of the day it is and working night shifts does not allow the brain to release melatonin. Stress increases cortisol production, keeping the body in arousal mode and not allowing it to rest. People who consume drinks with high concentrations of caffeine find it harder to relax by the end of the day as caffeine molecules, which are very similar to adenosine molecules, block adenosine receptors in our neurons. Adenosine makes neural activity sluggish and helps the brain relax but caffeine acts as an antagonist to this process.
  

• Infradian Rhythm- Infradian rhythm is another type of biological rhythm that takes more than 24 hours to occur. In the environment, these rhythms occur in the form of hibernation in animals, Seasonal Affective Disorder (SAD) or menstrual cycle in women. Infradian rhythms, also known as the body's second biological clock exert significant influence on the brain, metabolism, immune system, gut microbiome, stress response and reproductive system. In mammals, unlike the circadian cycle that is observed in both individuals of male and female physiology, the infradian cycle is observed in individuals with female physiology in the form of the menstrual cycle.

Talking about the menstrual cycle, a common misunderstanding that people and even most women tend to have is that menstrual cycle and menstruation are the same thing. So let's understand what menstruation is and what the menstrual cycle is. Menstruation, which is also known as a ‘Period’, is only a part of the menstrual cycle. The menstrual cycle, on the other hand, is a 28-36 day long cycle, including 4 phases that lead to different kinds of changes in the body at various levels in the body. The menstrual cycle is a result of hormonal interplay between the pituitary gland, ovaries and the hypothalamus. The main hormones that regulate the menstrual cycle include-

• Follicle Stimulating Hormone (FSH)- Released by the pituitary gland, the main role of FSH in regulating the menstrual cycle is to stimulate the follicle of ovaries that are filled with fluid and an egg to grow, mature and prepare for ovulation.

• Luteinizing hormone (LH)- Again released by the pituitary gland, the role of LH is to rupture the follicle that has been matured by the follicle-stimulating hormone and release the mature egg into the fallopian tube.

• Estrogen- Estrogen, mainly released by the ovaries, is responsible for the physical sexual development during puberty. In menstrual cycle regulation, estrogen or estradiol (E2), a type of estrogen, is responsible for the growth of the uterine lining and also the maturation of the egg before ovulation. This hormone is crucial to other functions of the body as well, for instance, the heart, bone density and functioning of the brain.

• Progesterone- Progesterone is the hormone that is released after ovulation by the Corpus Luteum, which is the ruptured follicle from which the egg is released which acts as a temporary gland to thicken the uterine lining and pregnancy. Progesterone’s main role is to thicken the uterine lining to support conception and pregnancy if the egg is fertilized but when the egg is not fertilized, the corpus luteum breaks and lowers the progesterone levels in the body. The decrease in progesterone leads to thinning and finally the breakdown of the uterine lining and leads to what is known as menstruation or menstrual period.

The interplay of these hormones leads to what is called as the Menstrual Cycle, which includes 4 phases lasting for differing numbers of days for each phase, with different amounts of release of hormones in the phases that impact not only sexual functioning but also mood, level of energy, insulin sensitivity and resistance, skin, stress response, amount of required sleep, nutritive needs etc. Let us now take a look at the various phases in detail-

1. Menstrual phase- This phase of the cycle, also known as the ‘menstrual period’, is the phase of bleeding where both the main reproductive hormones, estrogen and progesterone are at their lowest. It begins on the first day of the period with the shedding of the uterine lining in the form of blood and can last anywhere up to 3-7 days.

2. Follicular Phase- This phase of the cycle too begins on the first day of the period, overlapping with the menstrual phase and ending at ovulation. During this time, due to low estrogen and progesterone levels, the brain is signalled by the body to start releasing follicle-stimulating hormone to restart the cycle. As a result, the estrogen levels in the body keep rising till an egg matures and is finally released. The estrogen levels in the body are higher than progesterone levels at this stage.

3. Ovulation Phase- This phase occurs around the 14th day of the cycle with a sudden surge in the luteinizing hormone (LH), which leads to rupture of the mature follicle and release of an egg in the fallopian tube, which stays there for 24-48 hours.

4. Luteal Phase- This phase of the cycle starts right after the ovulation has occurred and is named after the corpus luteum, the temporary endocrine gland that supports the release of progesterone. In this phase, the progesterone levels begin to rise, halting the production of FSH and estrogen levels tend to decrease in comparison to progesterone. The main role of progesterone is to thicken the uterine lining to prepare for pregnancy. When the egg is not fertilized, the corpus luteum degenerates, progesterone levels decrease and the uterine lining starts thinning and thereby degenerates in the form of period blood through the cervix and the vagina and starts the menstrual phase. The rising progesterone also signals breast tissue to produce milk, which is why some people even experience breast tenderness before their period.

This infradian cycle in women when functioning optimally, leads to proper sexual functioning, less intense mood swings or a more or less stable mood, more productivity, normal period flow, light or no cramps, no clotted period blood, stable energy levels, proper digestion, metabolism and immune function but problems like Polycystic Ovarian Syndrome (PCOS), Endometrial Polyps and endometriosis etc can disrupt the normal function of the menstrual cycle. These are common problems that occur due to stress, disrupted eating and sleeping patterns and high cortisol levels in the body.

Now that there is a basic understanding of the menstrual cycle and its components, let us begin the main talk regarding Polycystic Ovarian Syndrome (PCOS). PCOS is a complex metabolic and endocrine disorder and not necessarily a reproductive disorder, which is typically characterized by anovulation, infertility, insulin resistance and polycystic ovaries. This disorder manifests itself as irregular periods, acne, hirsutism, male-patterned hair growth, alopecia, infertility, obesity, painful periods and low energy levels. Women with PCOS often are at a higher risk of developing ovarian cancer, breast cancer and type 2 diabetes than women who do not have PCOS, suffer from low self-esteem, higher body image issues, depression, anxiety, much more intense Premenstrual Syndrome symptoms (PMS) and report higher incidences of being diagnosed with Premenstrual Dysphoric Disorder (PMDD).

The causes of PCOS are yet unknown but a variety of factors over the years have been ruled out which can be possible causative factors in the development of PCOS. Studies have shown that various environmental factors like exposure to heavy metals, insecticides, pesticides, and endocrine-disrupting chemicals (EDCs) which are majorly found in a lot of products used by women, ranging from sanitary napkins to makeup and perfumes all contain chemicals that can hamper with the connection between the hypothalamus, pituitary gland and the ovaries, also known as the Hypothalamic-Pituitary-Ovarian (HPO) axis. Moreover, a study in Taiwan showed that increased exposure to air pollutant particles and gases namely SO2, NO2, NO and PM2.5 was associated with increased PCOS risk. The type of diet is also a contributing factor to the development of PCOS. Foods that are high in sugar (also known as high glycemic index foods) increase insulin resistance in the body. Insulin is the hormone that converts blood sugar into energy and allows this more ready-to-use form of energy to perfuse through the cells of the body. When too much of high glycemic index foods are consumed, the body has to release more and more insulin to break the same amount of glucose and over time, the cells of the body become resistant to the effect of the insulin. Just like in a person with an addiction to any kind of substance, to get the same high, they consume higher quantities of the drug therefore to convert the same amount of glucose into energy, we need higher amounts of the insulin hormone. This condition of excess production of insulin is known as Hyperinsulinemia, which meddles with the Hypothalamic-Pituitary-Ovary (HPO) axis by mimicking the action luteinizing hormone (LH), which disturbs the LH: FSH ratio and increases LH in the body, the hormone that is responsible for rupture of mature follicle and release of egg in the fallopian tube. This resultes in protrusion of follicular fluid from follicles that have not matured, forming the pearl-like cystic representation on the surface of the ovaries. This leads to an increase of free androgens in the body, causing hyperandrogenism, which is the main cause of most of the symptoms of PCOS like acne, thickening of hair on the chin (hirsutism) and anovulation etc. Insulin resistance is also the biggest cause of why women with PCOS always feel low on energy. The cells of the body that have over time become resistant to the action of insulin, are unable to use energy derived from the food taken and hence, the metabolic process of the body is also disturbed. Over time this insulin resistance also converts itself into type 2 Diabetes or Diabetes Mellitus.

Research also finds the answer to why PCOS even develops in the first place and rules out the possible dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis. A case-control study on stress and PCOS done on Indian women highlighted that women with PCOS had high levels of serum cortisol and Dehydroepiandrosterone (DHEA). They also reported high on the perceived stress scale. Cortisol, which is a stress hormone plays a role in the regulation of the stress response and DHEA is another hormone produced by adrenal glands that helps in producing other hormones, including estrogen and testosterone.

A theory in the field of functional medicine and naturopathy, known as the ‘pregnenolone steal syndrome’ postulates that all steroid hormones like progesterone, testosterone and cortisol are derived from pregnenolone, a precursor hormone derived from cholesterol in the body and in cases of acute or chronic stress, the body uses the available pregnenolone and prioritizes the production of cortisol in the body instead of the essential reproductive hormones, and in this case progesterone, because the human body has been designed from the beginning to prioritize survival over optimal function. This progesterone Deficiency in the body can lead to irregular periods, long and heavy periods, and elevated prolactin levels and some of the other symptoms of PCOS like acne, hair loss and severe PMS.

So far we have discussed the technicalities of the syndrome but understanding PCOS is not about knowing what goes inside a woman’s body with PCOS but rather understanding, feeling and generating empathy with people who fight PCOS. Taking my own story, being diagnosed with PCOS was physically, mentally and emotionally very tormenting for me. I used to have severely painful periods to the extent that oral painkillers did not work for me, my gynaecologist did not educate me much about the syndrome too. I was put on birth control pills, which is the so-called “only ideal solution” to the problem. A week into taking the birth control, I started having an allergic reaction to it and after that, I discontinued all the allopathic medication and switched to homoeopathy, with which I followed a very strict but nutritive diet and a good lifestyle, including sleeping for 8 hours at least, exercising and eating homemade food. After all this, my symptoms were minimised. However soon after coming to college, my symptoms exacerbated and were worse than earlier this time. This impacted my performance, relationships, self-esteem, body image and a lot more areas of my life, to the point where I still feel unrecognisable to myself. Throughout my cycle, I used to feel low, unable to push myself out of bed most mornings, I started crying daily and for most days of the month, I just felt tired and “done”. I did a little research into it and saw my behavioural symptoms matched that of Premenstrual Dysphoric Disorder (PMDD), so I sought professional help for it and was put on Selective Serotonin Reuptake Inhibitors (SSRIs) and have been doing better ever since.

This is just a little experience I’ve had with my PCOS but there are several women like me with PCOS who have low self-esteem, negative self-image and distress owing to physical changes caused by hyperandrogenism, hirsutism, acne, hair loss obesity etc. The relationship dynamics change and women with PCOS are a lot of times misunderstood and even sidelined in their friendships and relationships or face breakup of their relationships because of their unstable mood, increased impulsivity, feelings of not belonging due to their complexes or just finding it hard to reciprocate or actively initiate in relationships. Sudden changes in the body, mentally, emotionally and physically are already devastating and shameful and adding to the torment are the comments from the people around about increased weight, moodiness and the biggest concern for proving femininity “How will you conceive?”. Women with PCOS also report sexual dissatisfaction in relationships or in general due to changes in feelings of self-worth, self-esteem and sexual attractiveness. Even though it is presumed that increased androgen levels will increase libido, women with PCOS have rather reported having less sexual desires and thoughts than women without PCOS. Some women with PCOS also incur a condition called hyperprolactinemia, which is the excess of prolactin production in the body that causes symptoms of depression and anxiety. A study showed that patients with Major Depressive Disorder have high plasma prolactin levels (Elgellale, Larkin, Kaelle, Mills & Thomas, 2021) but apart from prolactin levels it is actually the fluctuations in the body, typically owing to an increase in body weight and obesity that is the main reason for depression and anxiety in women with PCOS. Women with PCOS fear not fitting the societal and cultural standards of beauty, fear gaining excess weight, changes in their appearance and experiencing overall dissatisfaction with their bodies. They are also at a higher risk of developing eating disorders, getting obsessed and hypervigilant with what they put in their bodies.

Women with PCOS have their fair share of troubles dealing with this problem and the least they want are comments on their appearance, let me give you a few examples-

“Dude, you look like a man”

“God, you have put on so much weight” And

“You have PCOS, right? I have heard you can’t get pregnant with PCOS”

First of all, it’s not right to just say anything that you observe about others to their face, you don’t seem ‘cool’. Secondly, get your facts checked about somebody’s condition before you say something about it and lastly, if you genuinely want to show empathy, ask them how it makes them feel, what changes they observed or in general, gain knowledge about what PCOS is or really any condition for that matter.

People tend to brag first and inform later. Let me simplify, most people tend to speak with half knowledge or just things they heard and pass it on mixed with their own biases and that is so dangerous because this is where false stories, lies and myths are born. In the same way, PCOS also carries a long list of myths that I am about to debunk-

• Myth 1- ‘Women with PCOS cannot get pregnant’- This is so common among people and sadly, even doctors specialized in this area feed this fear into their patients by misinforming them and pressuring them to go on birth control. I remember, my first gynaecologist was more concerned with me being able to reproduce than me being able to heal. This is absolutely untrue, if anyone has PCOS, they can still conceive naturally or seek help through treatments. Surely, some women do experience infertility but it does not mean that all women with PCOS do.

• Myth 2- ‘Everyone with PCOS is obese or overweight’- PCOS is an endocrine disorder and not a disorder of obese people. Anybody can have PCOS and their symptoms may vary or some people with PCOS may not have the typical symptoms. There are various causes of PCOS and lean women too have PCOS. It also has a name- ‘Lean PCOS’.

• Myth 3- ‘Birth control is the only solution and cure to PCOS’- This is personally the most infuriating one for me. NO, NO NO, Birth control is not at all a solution for PCOS. Taking birth control will alter the hypothalamic-pituitary-ovarian axis, release hormones favourably and induce your period every month giving you the illusion that your body is working well but as soon as you go off it, the subsided symptoms will return and maybe even in a much worse way.

• Myth 4- ‘All women with PCOS have unwanted hair growth’- Surely, Hirsutism which is male pattern hair growth is one of the features of PCOS but not all women have it and factors like ethnicity also have a role to play.

• Myth 5- ‘If you are looking not to get pregnant then PCOS is nothing to worry about’- The way a woman’s worth and proof of femininity has been reduced only to her ability to give birth with time is truly represented in this myth. PCOS is not just a fertility problem but it can also be a precursor to other issues like type 2 diabetes, high blood pressure, high cholesterol problems, sleep apnea, ovarian and endometrial cancer and mental health problems.

The society as a whole, including the medical system, the education system, the food industry and even the general population is collectively ignorant of health issues that women face. The education system does not give us enough information about our bodies, as may be required to know our bodies much better. Honestly, my curriculum did not teach me the role of hormones in getting a period, the phases of a menstrual cycle or even about nutrition to support myself. The food industry may sell foods labelled as “healthy” but may have the highest glycemic index and lowest nutritive value and the medical system may sell drugs that just mask symptoms and give a illusion that everything in our body is working appropriately. Some doctors may not feel the responsibility to empathize and to educate their patients, rather, they more often than not normalize misery. And it's not just these systems but even the general population that does so. It is actually an unconscious habit, or an unconscious contagious social disease, if I may say so, to make the life of a woman a compromised one.

PCOS is yet to come up with its etiology and cure but as of now, there is no cure for the syndrome in medical science. Here are however some ways it can be tackled and managed. The first step is to make lifestyle changes, this includes a diet that is not high in glycemic index but rather is a well-balanced and proportionate meal of proteins, fats and carbohydrates. These three macronutrients are the basic energy-giving parts of our diet. People with PCOS are advised to take a diet rich in protein and healthy fats as it takes much more time to process fats and proteins and the release of energy is more controlled than giving a spike of energy that is provided by carbohydrates, particularly simple carbs. This will help sensitize the cells of the body to the effect of insulin and not release large amounts of insulin, thereby controlling androgen production. To make this process more efficient, it is advisable to eat food in a particular order of fibre first, like eating salad, then the protein, fat and carbs. This will ensure that the energy release is gradual and consistent, the body does not experience insulin spikes, a person is fuller for longer periods and will also reduce cravings. . Lifestyle changes also include taking 8 hours of sleep and following a set routine, i.e.- correcting your circadian rhythm and also including any form of exercise at least 5 times a week. This could be anything, walking, jogging, yoga or strength training. Women with PCOS are advised to avoid high-intensity workouts, aerobics or cardio as all these exercises increase cortisol levels in the body which causes inflammation throughout the body and increases androgen production.

Women with PCOS can better manage their energy levels by tracking their menstrual cycle and ‘phase-syncing’ their workouts. The four phases of our cycle- follicular, ovulation, luteal and menstrual impact our energy levels and syncing them according to phases can help us conserve energy and ensure our body does not perceive physiological stress of any kind. In the follicular and menstrual phase when both estrogen and progesterone are low, our energy levels are naturally low so we should follow a low-impact workout routine. In the ovulation phase, when the estrogen is high which is a natural mood and energy booster, one can afford to do a few high-intensity workouts and in the luteal phase when progesterone is high, focusing on building strength is the best time.

We know by now that stress, both physiological and psychological, can exacerbate PCOS symptoms. Practising stress management techniques like meditation, relaxation techniques like tensing and relaxing of muscles, deep breathing, getting out in nature, humming or learning a new art form or hobby can be very relaxing. Apart from this, seeking professional help from a psychologist in the form of psychotherapy or from a psychiatrist in the form of prescribed medication can also be an intervention strategy for stress management and reduction.

I was diagnosed with PCOS 2 years ago and since then I have not been the same. Initially, I resisted my diagnosis but I was then actually keeping myself away from a beautifully transformative experience. I know that I talked about a lot of downsides of PCOS but there is a much bigger, brighter side of this syndrome. Apart from all of the torment it gave me, something it has helped me become is mindful. Mindful of what I put into my body, of how I am feeling, what steps I can take up to alleviate certain feelings, and how to sit with my feelings and try to still approach myself with compassion and more understanding even when I feel the lowest. Over two years, I have come to understand my body a lot better and it has increased my knowledge bank. I have learnt how our hormones are so influential in determining our health and that the mind and the body are intertwined. Lastly, I have come to understand what sometimes people who have lost their health or have certain mood disorders go through and that has certainly made me more empathetic.

References-

● Azizi, M., & Elyasi, F. (2017, March 8). Psychosomatic Aspects of Polycystic Ovarian Syndrome: A Review. Iranian Journal of Psychiatry and Behavioral Sciences. https://doi.org/10.5812/ijpbs.6595

● Benjamin, J. J., Maheshkumar, K., Radha, V., Koshy, T., Maruthy, K. N., & Padmavathi, R. (2023, July 1). Stress and polycystic ovarian syndrome-a case-control study among Indian women. Clinical Epidemiology and Global Health. https://doi.org/10.1016/j.cegh.2023.101326

● Elgellaie, A., Larkin, T. A., Kaelle, J., Mills, J., & Thomas, S. J. (2021, May 1). Plasma prolactin is higher in major depressive disorder and females and associated with anxiety, hostility, somatization, psychotic symptoms and heart rate. Comprehensive Psychoneuroendocrinology. https://doi.org/10.1016/j.cpnec.2021.100049

● Ghada Khafagy, Inas El Sayed, Shimaa Abbas & Saeed Soliman (2020) Perceived Stress Scale Among Adolescents with Polycystic Ovary Syndrome, International Journal of Women's Health, 1253-1258, https://doi.org/10.2147/IJWH.S279245

● Singh, S., Pal, N., Shubham, S., Sarma, D. K., Verma, V., Marotta, F., & Kumar, M. (2023, February 11). Polycystic Ovary Syndrome: Etiology, Current Management, and Future Therapeutics. Journal of Clinical Medicine. https://doi.org/10.3390/jcm12041454

Written By: Kashvi Magan

Associate Editor: Mansha Kapoor

Reviewed By:

Jaya Kumari (Content Team Coordinator| Editor-in-Chief)

Akshita Tanwar (Deputy Content Team Coordinator| Deputy Editor-in-Chief)

Shreeyanshi (Junior Content Team Coordinator)

Ananya Chauhan (Junior Deputy Content Team Coordinator)