Introduction

Polycystic ovary syndrome (PCOS) affects about 10% of all women in the UK and there is still some confusion about what the condition actually is.¹ Though PCOS is not classified as an autoimmune disease, those with PCOS experience a higher frequency of autoimmune diseases. This article will explain what PCOS is and describe its link with autoimmune diseases.

What is PCOS?

PCOS is a hormonal disorder characterized by excess insulin (the hormone responsible for blood sugar control) and excess androgen (a male sex hormone that is normally produced in low quantities within females).

Risk Factors and Causes

The exact cause of PCOS is not known but it has been associated with:

1. Insulin resistance: When the body's tissues are resistant to the effects of insulin, extra insulin is produced to compensate for the loss of effect.

2. Genetics: Having first- or second-degree relatives that have PCOS is associated with an increased risk of development. This association suggests a genetic link that is currently undergoing investigation to identify the specific genes involved with increased risk of PCOS.^{2, 3}

Symptoms and diagnosis

Symptoms of PCOS include:⁵

1. Irregular periods: The increased levels of insulin in PCOS causes an over secretion of testosterone, which interferes with the development of follicles in the ovaries. As a result, normal ovulation is disrupted, leading to irregular menstrual cycles.

2. Subfertility or infertility: Due to impediment of normal ovulation.

3. Excessive hair growth: Usually on the face, back, chest, or buttocks. This is known as hirsutism and is a result of the excess testosterone production.

4. Oily skin and acne: As a result of the excess testosterone production.

5. Thinning hair or baldness.

6. Weight gain and obesity.

Irregular periods, physical features such as facial hair (or blood tests showing high levels of "male hormones", such as testosterone), and polycystic ovaries on ultrasound are the 3 main features used to diagnose PCOS. If an individual has at least 2 of these features, they may be diagnosed with PCOS.¹

What is an autoimmune disease?

Autoimmune diseases occur when the body’s immune system mistakenly attacks its own organs, tissues, or cells.

Autoimmune diseases usually arise from a combination of genetic and environmental factors. An autoimmune disease could be inherited (genetic) or may be triggered by an infection (environmental or environmental with underlying genetic predisposition).

Common PCOS-linked autoimmune diseases

Autoimmune diseases are more frequently found in women with PCOS than in women without PCOS. Those that are linked with PCOS include:

• Type 1 Diabetes: where the immune system attacks insulin-producing cells in the pancreas leading to uncontrolled blood sugar levels and further complications.
• Systemic Lupus Erythematosus: in which the immune system attacks various tissues throughout the body including the lungs, skin, joints, blood cells, nerves, and kidneys.
• Celiac disease: a condition in which the immune system attacks the body’s own cells when gluten (a common protein found in various wheat, grain, and rye products) is ingested.
• Grave’s disease: where the immune system attacks thyroid cells and causes overproduction of thyroid hormones.
• Addison’s disease: in which the immune system attacks the adrenal glands.
• Hashimoto’s disease: in which the immune system attacks the thyroid glands and causes decreased production of thyroid hormones.⁴

Does PCOS increase the risk of autoimmune disease?

Studies that research the link between autoimmune diseases and PCOS are limited. Some researchers are of the view that PCOS increases the risk of developing autoimmune diseases, while other researchers believe that the link exists because the risk factors for both types of conditions are similar.

The argument for PCOS independently increasing the risk of autoimmune diseases is based on the theory that the hormone imbalance in PCOS causes an overstimulation of the immune system that leads to autoimmune attacks.

On the other hand, the argument that PCOS and autoimmune conditions are linked because they share the same risk factors is based on the theory that a disorder of the immune system and inflammatory response is responsible for the formation of the insulin resistance that triggers the development of PCOS. In this perspective, since a disordered immune system is also responsible for autoimmunity, it is reasonable to expect that it will be more likely to find PCOS and autoimmune disease in the same person.^{2, 4}

Diagnosis of PCOS

A diagnosis of PCOS can usually be made if at least 2 of the following 3 criteria are met:

• Irregular periods
• Physical features such as facial hair (or blood tests showing high levels of "male hormones", such as testosterone)
• Polycystic ovaries on ultrasound

These are the 3 main features used to diagnose PCOS. If an individual has at least 2 of these features, they may be diagnosed with PCOS. To confirm the diagnosis, there will also be investigations to rule out other rare causes of the same symptoms.¹

Treatment

PCOS cannot be cured. Treatment, therefore, focuses on managing the symptoms of the condition.

Weight loss and regular exercise to maintain a healthy weight are vital in managing symptoms of PCOS such as sub-fertility or infertility, menstrual irregularities, acne, and hirsutism. Individuals with COCP should make sure to consume enough vegetables and fruits, and have an overall balanced diet. Vitamin D supplements may also help.

When weight loss, exercise, and a good diet do not resolve the symptoms, pharmacological treatment may be added on. If you have issues with menstrual irregularities, your doctor may prescribe combined oral contraceptive pills or progesterone pills to manage this. In those with fertility issues, a drug called clomiphene citrate will be tried first before moving on to other options like gonadotropins or a surgery called ovarian drilling. For acne, benzoyl peroxide or retinoids may be attempted.

Other management activities include shaving if suffering from hirsutism.^{1, 3}

Summary

PCOS is a common hormonal condition that affects fertility, causes irregular menstrual cycles, and causes features such as facial hair in females. Though PCOS is not an autoimmune disease, it is linked with autoimmune conditions such as type 1 diabetes and Grave’s disease. Though PCOS is not curable, symptoms can be managed with weight loss, exercise, a good diet plan, and sometimes pharmacological interventions.