Your Thyroid and Polycystic Ovary Syndrome (PCOS)

Patient Expert

Polycystic ovary syndrome (PCOS) is a “hyperandrogenic disorder,” meaning that it involves an excessively high level of male hormones. PCOS is one of the most common hormonal disorders in women. Another widespread hormonal condition in women is an underactive thyroid, known as hypothyroidism. Experts are increasingly identifying links between these two hormonal problems.

If you have PCOS or hypothyroidism, here’s what you need to know about the connection.

PCOS patients and thyroid problems

One of the most common signs of PCOS — ovarian cysts — are also frequently seen in women with hypothyroidism. If you have ovarian cysts and your doctor suspects that you have PCOS, make sure that he or she evaluates your thyroid before diagnosing you with or treating you for PCOS. The panel of thyroid tests your doctor should run includes thyroid stimulating hormone (TSH), free thyroxine (Free T4), free triiodothyronine (Free T3), and the thyroid peroxidase (TPO) antibody test.

If you have already been diagnosed with PCOS, your doctor should still regularly screen you for thyroid problems. The reason? When you have PCOS, you have an increased risk of several thyroid conditions, including:

  • Goiter: The term for an overly enlarged thyroid gland.
  • Thyroiditis: The term for inflammatory conditions of the thyroid.
  • Autoimmune Hashimoto’s thyroiditis: An autoimmune disease that slowly destroys your thyroid. TPO antibodies are almost always elevated when you have Hashimoto’s thyroiditis. Research has shown that as much as 27 percent of women with PCOS also have elevated TPO antibodies — indicating that they have Hashimoto’s thyroiditis — compared to only eight percent in women without PCOs.
  • Subclinical or borderline hypothyroidism: Some studies have found that as much as 25 percent of patients with PCOS also had subclinical hypothyroidism, defined as a TSH level above 2.0 IU/L.

Recognizing the symptoms of hypothyroidism in women with PCOS can be a challenge for both patients and physicians because the symptoms are almost identical. Symptoms, such as ovarian cysts, weight gain, fatigue, hair loss, fertility problems, and erratic menstrual periods are, in fact, common to both PCOS and hypothyroidism. The bottom line: If you have PCOS, familiarize yourself with all the symptoms of hypothyroidism. If you experience any of these symptoms, ask your doctor to run a complete thyroid panel.

Thyroid conditions and the risk of PCOS

Experts don't know the exact cause of PCOS, but it appears that high levels of insulin, inflammation, and a family history of PCOS can all increase your risk of developing the condition. While Hashimoto’s thyroiditis or hypothyroidism do not directly cause PCOS, having these thyroid conditions appears to increase your risk of developing PCOS.

Diagnosing PCOS in women with Hashimoto’s and/or hypothyroidism is challenging, again because both conditions have many of the same symptoms.  For example, the symptoms of PCOS — as well as hypothyroidism — include:

  • Ovarian cysts
  • Menstrual problems, including heavy periods, irregular periods, infrequent periods, or missed menstrual periods
  • Failure to ovulate, known as anovulation, or anovulatory menstrual cycles
  • Weight gain
  • Fatigue
  • Hair loss from your head
  • Infertility
  • Mood changes, including depression and anxiety
  • Sleep problems, especially sleep apnea

There are three unique signs and symptoms, however, that are seen in PCOS but not usually seen in women with hypothyroidism. These signs and symptoms include:

  • Unwanted hair growth, especially on your face, arms, back, chest, fingers, toes, and stomach
  • Adult acne
  • Pelvic pain

If you have symptoms of PCOS, you may need to push your healthcare provider to run tests to diagnose or rule out the condition.

An essential step in the diagnosis of PCOS is an ultrasound to look for irregularities in your ovaries, such as ovarian cysts, enlarged ovaries, or a thickened uterine lining. Most women with PCOS show some ovarian changes on ultrasound.

As part of a PCOS diagnosis, your doctor is also likely to order blood tests, including:

  • Testosterone, androstenedione, and dehydroepiandrosterone (DHEA) — sex hormones that are usually elevated in women with PCOS.
  • Sex hormone binding globulin (SHBG), which is usually lower than normal in women with PCOS.
  • Estrogen, which may be higher than normal in women with PCOS.

If you are of childbearing age and want to become pregnant, your doctor may also test:

  • Follicle-stimulating hormone (FSH), which is frequently lower than normal in women with PCOS.
  • Luteinizing hormone (LH), which is sometimes higher than normal in women with PCOS.
  • Anti-Mullerian hormone (AMH) — a test to evaluate how close you are to menopause. AMH levels are usually higher than normal in women with PCOS.

Treating PCOS

If you are diagnosed with PCOS, it is vital that you receive treatment. When untreated, PCOS puts you at increased risk of many other health conditions, including:

  • Infertility
  • Obesity
  • Spontaneous and recurrent miscarriage
  • Metabolic syndrome
  • Prediabetes
  • Type 2 diabetes
  • Heart disease
  • Stroke

There are a number of ways doctors treat PCOS.

Weight loss: Losing some weight can help manage some of the symptoms of PCOS, reduce elevated blood sugar, and help counteract PCOS-associated weight gain. To lose weight, doctors often recommend a calorie- and carbohydrate-controlled, high-fiber diet.

Regular exercise: Exercise can aid in lowering your blood sugar and help with weight loss.

Birth control pills: If you aren’t trying to become pregnant, your doctor may prescribe birth control pills, hormonal patches, or a hormonal intrauterine device (IUD). These hormones can help regulate your menstrual periods and reduce male hormone levels, counteracting acne and excess hair growth.

Metformin: While it’s not FDA-approved for PCOS, many doctors prescribe the type 2 diabetes drug metformin (Glucophage) to treat PCOS. Metformin makes your body more sensitive to insulin, which helps reduce elevated blood glucose and insulin levels associated with PCOS. Metformin may help you lose some weight.

Spironolactone: When you are growing excess, unwanted hair — a condition known as hirsutism — doctors sometimes prescribe the drug spironolactone (Aldactone). This drug can also help with acne in some women. Spironolactone is not prescribed during pregnancy — or when you are trying to get pregnant — due to a risk of birth defects

Clomiphene: If you have PCOS and are trying to get pregnant, your doctor may prescribe clomiphene (Clomid) to help stimulate ovulation.

Other approaches to PCOS

Integrative and holistic physicians address PCOS with several treatment approaches, including:

  • Dietary changes, including reduction or elimination of starchy carbohydrates, elimination of dairy products, and cutting back on or eliminating caffeine and alcohol
  • Supplements to help support your intestinal health, reduce inflammation, lower blood sugar, and promote hormonal balance
  • Acupuncture, to help balance hormones
  • Mind-body approaches such as meditation, to reduce the stress response and support hormonal balance

An important note regarding metformin

If you are being treated for hypothyroidism, taking the drug metformin —frequently prescribed for PCOS, prediabetes, and type 2 diabetes — can suppress your TSH level, making it appear lower-than-usual without changing your circulating levels of T4 and T3 thyroid hormones. This poses a risk that your doctor may mistakenly lower your dosage of thyroid hormone replacement medication based on an artificially low TSH level. This situation could leave you undermedicated for your hypothyroidism and worsen your symptoms.

According to recent research published in the Journal of Endocrinology

"Depressed TSH level provides false reassurance or may prompt initiation of therapy, or endocrinologists may decrease [levothyroxine] dosage with spuriously low TSH level. The clinicians should consider the effect of metformin when they interpret thyroid function to avoid any appropriate treatment or adjustment of [levothyroxine] dosage."

Make sure that your doctor is aware that you are being treated with both thyroid hormone replacement medication and metformin before he or she makes any changes to your thyroid medication dosage.

See more helpful articles:

Thyroid Disease and Your Menstrual Cycle

The Risks for — and Symptoms of — Hypothyroidism

Thyroid Disease and Type 2 Diabetes