Dear Dr. Roach: I had all the symptoms of polycystic ovary syndrome (PCOS) when I was younger. I could go six months without having my period. I had all the other symptoms, too, like oily skin and facial hair. It’s a terrible thing for a young teenage girl. I also had trouble getting pregnant; though, fortunately, Clomid worked well for me during both of my pregnancies.
My question is, how does PCOS affect older women? My doctor doesn’t know. Is this why my hair is thinning so badly? What else can I expect now that I’m older? (I’m 66 now, and I had menopause at 51.) What can I do about it? I still have hot flashes and thinning hair.
L.L.P.
I’m sorry that you aren’t getting good advice. PCOS doesn’t go away after menopause, but it’s harder to diagnose. There aren’t good data to help guide treatment, so understanding what’s happening at a biochemical level is important.
Although cysts in the ovaries are usually seen with PCOS, the most important parts of the diagnosis have more to do with androgen excess (male hormones) and abnormal ovulation. Insulin resistance is also an important part of PCOS, with or without obesity.
The androgen excess is responsible for oily skin and facial hair, and it’s partially responsible for insulin resistance. As women age, most androgen levels tend to return to normal, but women may still have some residual symptoms. Although any woman may get female-pattern hair loss (overall thinning of the hair, often worst in the center part), women with PCOS are at a higher risk for developing this type.
However, women with PCOS may also occasionally develop male-pattern hair loss (receding hairline, thinning on the crown) when the ovaries produce excess male hormones and fewer female hormones. Treatment with the antiandrogen medication finasteride seems particularly promising, and topical (or possibly low-dose oral) minoxidil can be helpful. A dermatologist who specializes in hair loss should be the expert in the management of PCOS-associated female-pattern hair loss.
The excess male hormones may also play a role in increasing a postmenopausal woman’s risk for heart disease. HDL cholesterol levels tend to be lower in postmenopausal women with PCOS. The standard calculators to help a clinician decide when to start medication treatment (such as a statin) to reduce the risk of heart disease are likely to underestimate the risk. Thus, diet and exercise are very important for women with PCOS.
Hot flashes do not seem to be worsened by PCOS. Although hormone replacement can be used in women with hot flashes and PCOS, it is especially risky in a woman of 66 due to the increased risk of heart disease. Nonhormonal treatment, such as venlafaxine or fezolinetant, is my recommendation.
Finally, insulin resistance is present in over half of all women with PCOS, so regular evaluations of blood sugar levels and A1C levels are important to diagnose prediabetes or overt diabetes as quickly as possible. Again, diet, exercise and sometimes medication are even more important for women with PCOS, to help reduce the risk for developing diabetes.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
