What's the link between PCOS and diabetes?
Hormones are the body's chemical messengers and coordinate some of our most complex functions. But what happens when they go awry? We ask an endocrinologist and a gynaecologist to explore the most common hormone imbalances.
Seven years ago Rachael, now 28, went to A&E coiling over in severe pain. The pain radiated from her abdomen to her lower back, and it was difficult to pinpoint its origin. An ultrasound identified a large ovarian cyst which she had removed via surgery.
"I also experienced unwanted hair growth on my face and chest, weight gain, and very unpredictable periods," says Rachael.
She was diagnosed with polycystic ovary syndrome (PCOS), a condition related to abnormal hormone levels in the body, including high levels of insulin and excess androgens (male hormones).
Now an adult, Alexandra remembers the difficulty she had concentrating as a 12 year old. "I was sleepless, big-eyed and had severe mind fog. I couldn't sit still, follow a conversation or concentrate on anything. I had tremors and a resting heart rate of 119. A GP took both my hands and asked me to put my arms straight out with palms down and try to keep them steady. I couldn't. I was referred to an endocrinologist who diagnosed an overactive thyroid."
Both Alexandra and Rachael suffer from hormone imbalances.
The body contains many different types of hormones, including oestrogen, progesterone and testosterone in the ovaries; thyroid hormones in the thyroid; cortisol in the adrenal glands; prolactin from the pituitary gland in the brain; and insulin in the pancreas.
These hormones operate like chemical messages in your body, coordinating complex processes like metabolism and fertility. They can even influence behaviour. It's important to keep these hormone levels balanced to ensure the healthy functioning of our bodies and minds.
What kinds of hormone imbalance are there?
There are about 50 different hormones in the body, and as a consequence, a plethora of different hormone imbalances a patient can suffer from. These include diabetes, hypothyroidism (an underactive thyroid), hyperthyroidism (an overactive thyroid), and Addison's disease.
Dr Simon Aylwin, consultant endocrinologist at London Bridge Hospital (part of HCA Healthcare UK), says: "The most common disorders include: menstrual disturbance due to polycystic ovary syndrome (PCOS), which leads to infrequent periods, unwanted hair growth and acne; underactive thyroid causing a general slowdown in a lot of body functions, and tiredness, brain fog and weight gain; an overactive thyroid causing weight loss, irritability and palpitations; and low testosterone in males, leading to reduced sexual interest and lack of drive and energy."
The symptoms that lead to a referral vary widely depending on age and gender. Depending on the hormone imbalance, a patient may experience a combination of different symptoms, including but not limited to: tiredness; insomnia; sensitivity to cold; constipation or diarrhoea; increased or decreased appetite; depression; mood swings or behavioural changes; muscle weakness; hair loss; irregular periods; a fast heartbeat; fatigue; stunted growth; vaginal dryness; sexual dysfunction; insomnia; weight loss or weight gain; anxiety; craving salt or sugar; and abnormal blood pressure.
How to diagnose a hormone imbalance
The variety of different hormone imbalances means there are lots of different methods for diagnosis, and for treatment or management of symptoms. Sometimes hormone imbalances may be suspected based on symptoms or indicated based on blood result tests - eg, the HbA1c test for diabetes, or FT4, TSH and FT3 tests for thyroid function.
People with a suspected hormone imbalance will likely be referred to an endocrinologist. Those with an imbalance of sex hormones like progesterone or oestrogen may be referred to an endocrinologist and/or a gynaecologist. "Endocrinologists see people with too much or too little of a number of different hormones," says Aylwin. "In general, heavy periods are best seen by gynaecologists, while light, absent or infrequent periods are mostly endocrine in nature."
"Women with PCOS have high oestrogen and testosterone levels," says Caroline Overton, consultant gynaecologist and spokesperson for the Royal College of Obstetricians and Gynaecologists. To diagnose PCOS, your doctor will look at your symptoms and run several tests. PCOS typically causes irregular periods; other common symptoms include weight gain and unwanted hair growth. Cysts can be seen via an ultrasound, while blood tests look for an excess of androgen hormones.
"Premenstrual syndrome is caused by an imbalance of female hormones and a progesterone dominance in the days before the period."
Perimenopausal women approaching the menopause often experience hot flushes and dryness of the vagina due to a lack of oestrogen. A patient can present these symptoms earlier due to a hormone imbalance. Your oestrogen levels can be tested by checking the blood levels of follicle-stimulating hormone (FSH.) Your FSH levels increase as oestrogen decreases.
What can you do about a hormone imbalance?
After you have a diagnosis, treatments vary depending on the hormone imbalance. For people with type 1 diabetes, insulin injections are necessary to produce the insulin the pancreas can't. While those with an underachieve thyroid gland usually take daily hormone replacement tablets to level out their hormones.
Alexandra managed her overactive thyroid gland by taking thyroid suppression drugs and beta-blockers. She also took radioactive iodine on two occasions, when she was 13 and again when she was 15.
Rachel looked into lifestyle changes to manage her PCOS. "Overweight and obesity lead to worsening of polycystic ovary syndrome, and the symptoms can be improved by weight loss and improved fitness," reveals Aylwin. "But most other hormonal disorders are not affected by lifestyle."
Another exception is type 2 diabetes, which is often linked to being overweight and inactive. The pancreas produces some insulin, but not enough. Eating well, staying physically active and watching your cholesterol can all help. Type 1 diabetes is not lifestyle-related and is classed as an autoimmune disease, not a hormone imbalance, where the pancreas, for whatever reason, is unable to produce insulin.
"I think my PCOS symptoms are gradually getting worse," says Rachael. "I’m trying to lose weight by going to the gym and eating healthily. PCOS makes you gain weight though, so it's harder. I manage my symptoms the best I can. I see a gynaecologist once a year and get an ultrasound to check my ovaries. I also have hormone tests to check my hormone levels. I own mostly black underwear and take pads everywhere I go, knowing how unpredictable my cycle is. It helps that I have a really loving partner who doesn't care about the hair and stuff. Being a fairly confident person I don’t let it affect me too much."
"The combined hormonal contraceptive pill can correct many of the gynaecological hormone imbalances," points out Overton. "It can help reduce the symptoms of PCOS and regulate irregular periods as well as providing contraception. It can also balance hormones in premenstrual syndrome and in the perimenopause."
Rachael went on the combined pill for this reason: "It helped with the unwanted hair growth, but it gave me depression as a side effect so I had to come off it. When I came off the pill I experienced mood swings."
Many herbal supplements claim to be effective in balancing hormones, including maca and royal jelly. But the evidence is lacking for the majority.
"Hormones are seldom affected by supplements, with one important exception," says Aylwin. "The UK has become more iodine-deficient as iodine is no longer routinely added to salt. Iodine is present in fish and dairy products and therefore those who avoid these items are at risk and may benefit from iodine supplements. A low iodine level can lead to thyroid dysfunction and an underactive thyroid." For vegetarians and vegans, it is also naturally present in seaweed.