Perimenopause is the transition leading up to menopause, when changing hormone levels can affect your periods and how you feel. Menopause is reached when you haven’t had a period for 12 consecutive months, provided there’s no other cause. Hormonal contraception can make this harder to identify, so your GP can help you understand where you are in the transition. The years afterwards are known as postmenopause.

First things first, a doctor needs to rule out and exclude other conditions, and then you would need to meet the diagnostic criteria. In the UK, we use a system called the Rotterdam Criteria. If you’ve got two out of the three features below, you meet the definition.

Oligo — infrequent ovulation which leads to irregular or absent periods

Hyperandrogenism — high levels of androgens (male sex hormones), determined either via a blood test or by observing clinical symptoms like acne, male patterned baldness, or excess hair growing in typically male areas, like the face, back and chest

Polycystic ovaries — this refers to an ovary that contains around twice as many fluid filled sacs or cysts than normal. These are in fact follicles, and are not to be confused with ovarian cysts. Often described as a 'string of pearls,' these are follicles that have become stuck and are visible via an internal scan. In a healthy cycle, a few follicles start to develop, and one is chosen as the top recruit to fully develop to then be released as an egg. In PCOS, no follicle ends up being picked for maturation, so they all end up sitting on the fence (or in this case, just below the surface of the ovary). This is why ovulation doesn’t occur, as no fully matured egg burst its way out of the sacs due to low levels of oestradiol.

Ovarian "cysts" (aka stuck follicles)

Absent or irregular period

Irregular ovulation, or failure to ovulate

Obesity

Difficulty losing weight, particularly around the middle

Difficulty getting pregnant

Pregnancy complications and miscarriage

Excessive hair growth (hirsutism)

Male patterned baldness and thinning hair

Acne

Skin tags

Acanthosis nigricans (darkened patches of skin)

Mood changes

Anxiety and depression

Fatigue

Brain fog

Skin conditions like eczema and psoriasis

Sleep disorders

IBS

Originally called the Stein-Leventhal syndrome, named after the American doctors who discovered it in 1935, PCOS was first considered and defined as a problem of anovulation and infertility. Since its original definition in the 1930s, it has undergone varying definitions, with debate and controversy surrounding the syndrome’s definition and diagnostic criteria ever since.

There is no one cause for PCOS. It's a complex combination of factors that lead to an expression of PCOS. What the research tells us is that it is thought to arise from genetic and environmental factors; with inflammation, elevated cortisol and insulin resistance at the driving seat alongside gut dysbiosis, an unstable circadian rhythm and exposure to endocrine disruptors (e.g. plastics and products). These factors interact to cause the features of PCOS to present themselves. That’s why PCOS responds so positively to diet and lifestyle changes as the expression of it is very much dependent on the condition of the body and the environment that the body is living in.

More research is needed but it's considered a heritable syndrome as it is prevalent within family clusters with some theorising that it potentially could be a complex genetic trait disorder. If we get into the nitty gritty, there is likely a fundamental issue with a process called aromatisation. This is where our oestrogen comes from, which is actually created from testosterone via an enzyme called aromatase. A little like the illuminated dry ice doors of Stars in Your Eyes, a transformation occurs and testosterone steps through the doors and becomes oestrogen – all thanks to aromatase. With PCOS this pathway is sluggish and doesn’t work very well. Via a loop system in the body, we then throw more testosterone into the mix with the aim to make oestrogen, as it notices it’s running low. The low levels of oestrogen (oestradiol) then mean we don’t ovulate but we keep on cueing the brain to make more testosterone. That’s when we get into a high testosterone pickle, causing PCOS symptoms to flourish. In the process of this pickle, oestrogen receptors can become damaged which puts even more stress on the situation as you become less sensitive at noticing oestrogen is even there.

The pill has also been cited as a potential trigger too due to its negative impact on our sex hormone binding globulins and nutrient status. It is complex and more research is needed but we likely need a genetic blueprint for PCOS alongside a combo of drivers to trigger and mediate hormonal dysregulation which then creates an environment which amplifies an expression of PCOS.

A combination of drivers alongside nutrient status, diet and lifestyle will create an environment for PCOS to flourish. There are three main dominant drivers to be aware of:

Insulin Resistance driven PCOS – this is the most prevalent driver accounting for about 70-80% of cases. In a nut shell, when your body starts to become less sensitive to insulin, we need more of it to get the same job done (which is moving glucose out of the blood stream and into the cells). Where there is insulin resistance a number of negative things happen in the body and one of them is raised testosterone. There are lower levels of sex hormone binding globulins – these are proteins that take sex hormones from A to B, just like a bus. If there are less busses running we get a backlog of testosterone waiting at the bus stop. We also see enlarged theca cells in the ovaries, which can over produce testosterone. Signs can but not limited to include elevated insulin, sweet cravings, skin tags, brain fog, excess weight around the middle

Inflammation driven – The body treats chronic conditions like PCOS the same as an infection or acute injury and sends over immune cells to try and heal the situation – instead of solving the issue this causes chronic inflammation and these inflammation markers are highly correlated with elevated androgen levels (testosterone). Signs of inflammation driven PCOS can be but not limited to fatigue, joint pain, skin conditions like psoriasis and eczema and IBS.

Adrenal driven PCOS – there is one androgen that is only made by the adrenal gland and that is DHEA-S. Via a blood test if all your other androgens are not elevated but this one is we can identify the issue is with the adrenals. We would call this adrenal androgen access. This is the least common with around 20-30% of women with PCOS. Adrenal PCOS is not driven by insulin resistance or inflammation. Instead, it’s an epigenetic upregulation of adrenal androgens.

Women with PCOS are at higher risk of the following health concerns:

- Pregnancy complications

- Increased prevalence of early pregnancy loss

- Gestational diabetes

- Pregnancy induced hypertensive disorders

- Birth of a small for gestational age baby

- Type 2 diabetes and impaired glucose tolerance are risk factors for women with PCOS - estimated present in 40% of PCOS suffers.

The Rotterdam PCOS workshop found that women with PCOS where at an increased risk of cardiovascular disease (Rotterdam).

- The NHS state an increased risk of the below conditions with a diagnosis of PCOS:

- Type 2 diabetes

- Depression and mood swings

- High blood pressure, high cholesterol, heart disease and stroke

- Sleep apnoea

I united the latest scientific research with my own clinical experience and personal journey with the syndrome and founded The Positive Method - The Path to Happier Hormones. This 6 pillar method is a uniquely colourful and evidence based approach to improve the symptoms of PCOS. When I work with a PCOS client, I then tailored the method to the individual because we are as individual on the outside as we are on the inside - each person's case will be different. This is because we have variable drivers at play - it is not a one size fits all. My passion is to get to the root cause of what is driving an individual's case and this is done by working together over a 3 month period. Once we do this - amazing things can happen.

I have worked with Global consumer healthcare provider GlaxoSmithKline, supporting consumer research into a personalised nutrition service for PCOS sufferers. Having an opportunity like this to understand how we can better support the PCOS community on a global scale is a true privilege.

I am on the medical advisory board for the PCOSAA (Polycystic Ovarian Syndrome Awareness Association) and was appointed the UK Ambassador in 2020. The PCOS Awareness Association is a non for profit organisation dedicated to raising the awareness of this disorder worldwide, providing educational and support services to help people understand what the disorder is and how it can be treated. I have hosted many webinars on the topic and was honoured to have been invited onto the expert panel for the PCOS Awareness Association's international 2020 annual event to promote PCOS education and raise awareness.

It's my job as a Nutritionist who specialises in this field to make a raise awareness, all in the hope that more women who are suffering are given the chance to learn more about the condition and take a positive step towards turning the volume down on their symptoms. If you want to start your journey with me to understand and improve your symptoms, book your free discovery call below