In an upcoming memoir, Live Wire: Long-Winded Short Stories, daytime talk-show host Kelly Ripa shares a story that has many people talking. The story, outlined in Haute Living, is in a chapter entitled “Don’t Let Your Husband Pick Your Death Clothes.”
As Ripa related, in 1997 as a new mother she passed out during sex with husband Mark Consuelos. Severe pain from a ruptured ovarian cyst was the culprit. When she came to in an emergency room, she found herself wearing clothing that Mark had quickly put on her — a 1980s-style French-cut leotard, red Manolo Blahnik shoes, plus a pair of her husband’s warm-up pants with side snaps.
She wrote: “My eyes shift between the fuzzy images on the screen, the remnants of my ovarian tormentor, and Mark happily snacking away. Sex can be so traumatic I think, and yet one of us is completely undaunted. There he is, happily munching on the saltines now and ordering a second apple juice …. I’m flat on my back wondering when the other two cysts will burst.”
Ripa added: “Also, here is my husband, who is, dare I say, stylish, well-dressed at all times, and yet he dressed me like a dime store prostitute in my time of need. It’s still baffling to me to this day that this is the best costume for the day that he could find for me, to the point where, when I was on the stretcher, I thought I was dreaming; I was having a nightmare. I didn’t realize I had come to.”
Ripa is just one of many celebrities who have revealed their struggles with polycystic ovary syndrome (PCOS). Others include Jillian Michaels, Lea Michele, Daisy Ridley, and Keke Palmer. Kelly Clarkson, in 2019, had an ovarian cyst rupture right in the middle of taping The Voice.
PCOS: The Most Common Hormonal Disorder in Females of Reproductive Age
PCOS is the most common hormonal disorder in females of reproductive age, affecting between 4% and 20% of women in that group worldwide (as many as 5 million in the U.S. alone).
According to the American College of Obstetricians and Gynecologists (ACOG), women with PCOS usually have at least two of the following three conditions:
- Absence of ovulation, leading to irregular menstrual periods or no periods at all
- High levels of androgens or signs of high androgens, such as having excess body or facial hair
- Cysts on one or both ovaries
PCOS is the most common cause of anovulatory infertility. Many women aren’t diagnosed with PCOS until they have difficulty getting pregnant. PCOS can cause other problems as well, such as unwanted hair growth (hirsutism), dark patches of skin, acne, weight gain, and irregular bleeding.
Women with PCOS are also at higher risk for:
- Obstructive sleep apnea
- Insulin resistance
- Metabolic syndrome
- Type 2 diabetes: more than half of women with PCOS develop type 2 diabetes by age 40
- Gestational diabetes
- Heart disease and high blood pressure
- Mood disorders
- Endometrial hyperplasia (a condition in which the lining of the uterus becomes too thick), and endometrial cancer
Etiology and Pathophysiology
The etiology of PCOS, although currently unknown, is most likely multifactorial, with contributions from genetic and environmental factors.
Most of the symptoms of PCOS are caused by excess levels of androgens, along with high levels of insulin and insulin resistance.
High levels of androgens can:
- Interfere with signals from the brain that normally result in ovulation, with the result that ovulation does not occur regularly
- Cause the ovarian follicles to enlarge, forming cysts
- Produce other symptoms of PCOS, including excess hair growth and acne
Too much insulin also increases the production of androgens, which then cause symptoms of PCOS. High levels of insulin can also increase appetite and lead to weight gain. High insulin levels are also linked to a skin condition called acanthosis nigricans, which results in thickened, dark, velvety patches of skin.
Treatments to Relieve Symptoms
There is no “cure” for PCOS, although there are many things that can be done to relieve symptoms and improve quality of life.
For many women, the first recommendations from healthcare providers are to follow a lower-calorie diet, lose weight, and get more physical activity. According to ACOG, weight loss of even 5-10% can yield significant clinical improvement.
A 2015 8-week study showed that a low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity, and reduced testosterone in women with PCOS.
Oral contraceptives can be used long-term for women who do not wish to become pregnant. The combination of estrogen and progestin in women with PCOS makes menstrual periods more regular, reduces the levels of androgen made by the ovaries, and helps clear acne and reduce excess hair growth.
These types of medications make the body more responsive to insulin and keep glucose levels more stable. In women with PCOS, these medications can help:
- Clear acne and reduce hair growth
- Improve weight loss
- Lower cholesterol levels
- Make periods more regular
- Slightly reduce infertility associated with PCOS
The FDA has not approved any insulin-sensitizing medications, such as metformin, specifically for treating PCOS, although the drug is often prescribed off-label.
These medications either prevent the body from making androgens or limit their activities or effects. Anti-androgens are helpful in lowering androgen levels, reducing excessive hair growth, and clearing acne. Because anti-androgens can cause birth defects, they are often taken with oral contraceptives to prevent pregnancy.
Removing or Hiding Unwanted Hair
There are many ways to remove or hide excess hair. These include:
- Shaving, bleaching, plucking, waxing, or using depilatories
- Electrolysis, laser hair removal, and intense pulsed light therapy — although these methods are often expensive and require multiple treatments
Retinoids, antibacterial agents, and antibiotics may be used to treat acne. Because retinoids can cause birth defects, however, they should not be used in women who want to become pregnant.
Treatments for PCOS-Related Infertility
- Clomiphene is the most common treatment for infertility in women with PCOS. ACOG recommends that clomiphene should be the primary medication for PCOS patients with infertility
- Clomiphene indirectly causes eggs to mature and be released
- Women treated with clomiphene are more likely to have twins or triplets than women who get pregnant naturally
- Although this insulin-sensitizing drug is normally used to treat diabetes, it may also be used as an adjunct to increase or regulate ovulation in women with PCOS
- Metformin can be used alone or with clomiphene when clomiphene alone is not successful
- Evidence shows that metformin — whether alone or in combination with clomiphene — increases ovulation, but it does not increase the rate of pregnancy
- Metformin is not approved by the FDA for treating PCOS-related infertility
- This drug transiently slows estrogen production and causes the body to make more follicle-stimulating hormone, which is needed for ovulation
- These hormones, given as shots, stimulate ovulation
- The treatment, however, is costly and has a higher risk of multiple pregnancies than does treatment with clomiphene
- This surgery may increase the chance of ovulation and may be considered if lifestyle changes and medications have already been used without success
- It is unclear whether this treatment, which is not recommended by all professional societies, is more effective than medications for treating PCOS infertility
- In ovarian drilling, the surgeon makes a small cut in the abdomen, inserts a laparoscope, and uses a needle with electric current to puncture and destroy a small part of the ovary. The surgery leads to lower androgen levels, which may improve ovulation
- This surgery may be less costly than treatment with gonadotropin, and it does not seem to increase the risk of multiple pregnancies. However, it does carry the risk of scarring the ovaries
In Vitro Fertilization (IVF)
For women who do not get pregnant with the treatments listed above, IVF may be suggested. In this procedure, sperm and an egg are placed in a dish outside the body, in which fertilization occurs. A doctor then places the fertilized egg into the uterus.
IVF may offer women with PCOS the best chance of getting pregnant, and it may give healthcare providers better control over the risk of multiple births. But it can be expensive and may not be covered by healthcare insurance.
Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children’s Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.