Does PCOS Affect the Vaginal Microbiome?

What is PCOS?

Polycystic ovary syndrome (PCOS) is a complex condition that affects approximately 10% of reproductive-aged people with ovaries worldwide. It influences multiple body systems, but the metabolic, reproductive, and endocrine (hormonal) systems are particularly impacted.

The medical definitions and criteria for PCOS vary, but most diagnostic guidelines agree that people with PCOS must present with at least two of the following three clinical findings:

• High levels of androgens (male sex hormones) in the bloodstream
• Irregularities in menstruation and ovulation
• Multiple cysts (fluid-filled sacs) on the ovaries

PCOS can have a profound impact on the physical and psychological well-being of people living with it. Let’s dive in and learn more about PCOS and how it can affect health and of course, the vaginal microbiome! 

What causes PCOS?

While many hypotheses exist, no single explanation has emerged as an undisputed answer to the question: what causes PCOS? Gender health gap, we meet again!

Most current research agrees that hormonal imbalances likely play an important role in its development. The ovaries of people with PCOS typically produce excessive levels of androgen hormones (testosterone and its precursors). 

Additionally, people with PCOS often display irregularities in their insulin hormone signaling systems, which can impair the body’s ability to process the sugars from food. However, researchers still don’t fully understand what triggers the development of these hormonal imbalances. Here are a few current hypotheses:

• Environmental pollutants may contribute to the development of PCOS

• Contaminants and chemicals in drinking water and certain food products may disrupt the endocrine system, leading to hormonal imbalances. 

• Environmental factors may interact with certain genes and lead to PCOS development.

• Some environmental chemicals appear to change how genes are “activated” (or not activated), which can lead to disease development. These changes in gene activation may even be carried through to the next generation.

• PCOS may begin even before birth, during fetal development in utero.

• Some babies who are born with either low or high weights appear to be at risk of developing PCOS. As they grow, they may begin puberty early and then develop classic signs of PCOS during their teen years. 

Despite this abundance of hypotheses, there’s no single theory that adequately accounts for all aspects of PCOS and its development.

What are the symptoms of PCOS?

In addition to the three key clinical signs we discussed above, people with PCOS often experience a variety of other symptoms as well. Common symptoms of PCOS include:

• Obesity
• High blood sugar (diabetes or pre-diabetes)
• Fertility and pregnancy problems
• Sleep apnea
• Mood disorders like depression and anxiety

PCOS also increases one’s risk of developing other medical conditions like metabolic syndrome, cancer of the uterine lining (aka endometrial cancer), and cardiovascular disease, particularly after menopause.

Although PCOS can be present from a young age, many of these common symptoms, like obesity and decreased fertility, don’t become obvious until one is in their twenties or thirties. For this reason, PCOS often isn’t diagnosed until a person exhibits other conditions like these.

How is PCOS diagnosed?

There is no single, simple test for PCOS. Several diagnostic guidelines for clinicians exist, each with similar, but not identical, criteria.

As we mentioned earlier, a person must have at least two of the three key findings–polycystic ovaries, menstrual irregularity, and high androgen levels–to be diagnosed with PCOS. 

The presence of just one of these findings neither guarantees nor rules out a diagnosis of PCOS. The term “polycystic” in the name implies that a person must have many cysts on their ovaries to be diagnosed with PCOS, but this isn’t always the case. Some people with PCOS won’t have ovarian cysts that appear on ultrasound images. 

Current research cautions against diagnosing PCOS based solely on ultrasound imaging of the ovaries. There is some disagreement about how many cysts are “too many” and what size the cysts must be to be considered problematic. 

Given these discrepancies, it’s perhaps unsurprising that it takes an average of two years and consultations with three different healthcare providers to receive a PCOS diagnosis. Understandably, this slow diagnostic process often causes patients to become frustrated and dissatisfied with their care.

How is PCOS treated?

We don’t understand what causes PCOS, so unsurprisingly, we don’t yet have a cure for it. Currently, treatment focuses on managing each individual’s unique symptoms. Multiple treatment approaches are often required to target the various symptoms that PCOS can cause – these include:

• Contraceptive medication to regulate menstruation and suppress androgen hormones
• Medications to reduce insulin resistance in people with PCOS-related diabetes
• Lifestyle changes to promote weight loss and prevent other health problems that have yet to develop, such as diabetes or heart disease
• Vitamin D supplementation, particularly for people struggling with decreased fertility
• Psychological therapy and medication for depression and anxiety

Managing fertility issues related to PCOS is a field unto itself. Fertility specialists have developed complex treatment protocols specifically for people with PCOS. Many people with PCOS first receive the diagnosis when working with a fertility specialist to become pregnant. Fortunately, researchers are continually working to develop more effective, safe ways to help people with PCOS conceive if they so choose.

A note on fatphobia in medicine and PCOS

It’s very common for people with PCOS to have increased body weight. From a strict medical perspective, this can be monitored in case it could be contributing to other health problems. However, increased body weight very often presents a barrier to appropriate care. 

Too many people with PCOS report negative medical experiences related to their weight. Many are simply told to “lose weight” without receiving the tools to do so in a safe and effective manner. Fat shaming is a well-documented phenomenon in healthcare, and it often leads to delays in the diagnosis and management of PCOS. 

Interestingly, a 2007 review reported that while up to 80% of Americans with PCOS are overweight or obese, this rate is much lower outside of the United States (as low as 20% in some places). This suggests that increased body weight isn’t always a direct result of PCOS, but may be at least partly related to lifestyle factors specific to the United States. 

If you live with increased body weight and suspect you could have PCOS, don’t be afraid to self-advocate to ensure that your concerns are being heard – this is an unfortunate but necessary reality of existing under the modern American medical system. 

Many advocates within the fat acceptance community have pioneered strategies for reducing weight stigma in medicine. We still have a long way to go, but PCOS and body positivity influencers are paving the way every day!

How does PCOS impact the body’s microbiomes?

You know us: it wouldn’t be an Evvy article without some mention of the vaginal microbiome! Let’s explore how PCOS can impact the microbiomes of the gut and vagina.

PCOS and the Gut Microbiome

The microbiome of the gut (aka the GI system) is highly diverse, made up of 300-500 different microbial species on average. It influences digestion, the immune system, and a host of other important bodily functions. 

Research has established that the gut microbiome can impact the development of obesity and diabetes. Additionally, the gut microbiome and circulating hormones in the bloodstream can affect each other in both directions.

Given these connections, it’s perhaps unsurprising that recent research is demonstrating correlations between the gut microbiome and the development and course of PCOS.

The research on the gut microbiome and PCOS is growing fast. A recent review systematically analyzed the results of twelve different studies examining the gut microbiome in people with PCOS.

The results of these studies generally agreed that the gut microbiomes of people with PCOS are more diverse than those without PCOS. They noted that, relative to people without PCOS, the gut microbiomes of those with the condition exhibited:

• Increased levels of disruptive bacteria: Prevotella, Bacteroides, and Escherichia
• Decreased levels of protective bacteria: Lactobacillus and Bifidobacteria

PCOS and the Vaginal Microbiome

Remember how we’ve been geeking out over the growing body of evidence showing the connection between the gut and vaginal microbiomes (aka the gut-vagina axis)? Nerd-alert: It’s also likely that PCOS-related disruptions of the gut microbiome could also impact the vaginal microbiome! 

Unfortunately, research on PCOS and the vaginal microbiome is still quite sparse (thanks, gender health gap!) 

Additionally, the majority of published work in this area originates in China, a predominantly homogenous population, which limits our ability to generalize the research findings to racially diverse groups of people.

Here’s what we know right now:

• The vaginal microbiomes of people with PCOS have higher overall diversity and lower levels of protective Lactobacilli species than those of people without PCOS. 

• These findings were similar across studies in three different Chinese cities: Shanghai, Shandong, and Nanjing. 
• Given that Lactobacilli levels decline in response to decreased estrogen levels, and that people with PCOS have imbalances in their estrogen levels, these findings seem logical.

• The research is in conflict regarding the other bacterial species potentially affected by PCOS. 

• Some evidence suggests that Mycoplasma species are elevated in the vaginal microbiomes of people with PCOS. These data even suggest that Mycoplasma could potentially serve as a biomarker when designing new tests to screen for PCOS, however more research is needed to confirm this finding. 

At the moment, the research on the vaginal microbiome in PCOS is simply too sparse for us to draw definitive conclusions about the role of specific bacteria in the vaginal health of people with PCOS. 

As always, Evvy will keep pushing for more research to help us better understand the conditions that can impact the health of everyone with a vagina. If you have PCOS and want to take better charge of your health, check out the Evvy Vaginal Health Test and start learning about your vaginal microbiome today.