PCOS: what is this syndrome that Mel Charlot, new jury of Dancing with the Stars, suffers from?

Canadian dancer Mel Charlot is the new juror of Dance with the stars. If her smile shines on the TF1 prime every Friday evening, the choreographer, having notably worked with big stars like Beyoncé, Puff Daddy or Pharell Williams, has gone through some health concerns. “I have polycystic ovary syndrome. When I was diagnosed, the doctor warned me that I would probably never have children, since women with this condition ovulate less and are more at risk of miscarriage. The day before starting a contract, I didn’t feel like I usually do. I took a pregnancy test which came back, to my great surprise, positive.“, she confided in an interview with 7 Days TV in September 2023. Associated with metabolic complications, polycystic ovarian syndrome (abbreviated PCOS) would affect approximately 10% of women of childbearing age, a figure probably underrated due to its complexity and the slow diagnosis.

Polycystic ovarian syndrome (PCOS) is hormonal imbalance which was first described in 1936 by two gynecologists from Chicago (Stein and Leventhal) in young women who had problems withlack of rules and who wanted to start a pregnancy. “Many of them had problems associated with the fact that their ovaries produced too many male hormones (called androgens – which include testosterone – which are precursors of estrogens in women). These two doctors decided to operate on these young women because they had noticed that their ovaries were too big. The operation showed that these ovaries looked like small billiard balls, without a corpus luteum scar, indicating lack of ovulation. The authors therefore carried out a reduction in the volume of these ovaries by partial resection and noted the presence of a microcystic appearance on anatomical examination. Due to the return of menstruation and in several cases the start of pregnancy, the authors defined this clinical condition as polycystic ovary syndrome.” says Professor Michel Pugeat, professor emeritus, endocrinologist specializing in PCOS. Finally, the arrival of ultrasound showed that it was not a question of ovarian cysts but of microfollicles which, contained in the ovaries, were blocked in their maturation and produced too much androgen. Despite this rectification, the etymology “polycystic” was kept.

How many women in France are affected by PCOS?

“It’s a syndrome which probably concerns 10% of the female population of childbearing agethat is to say first period until menopause. It is difficult to make a precise assessment, but almosta million women would be affected by polycystic ovary syndrome in France (whether it is a complete form or a minor form). A figure probably very underestimated“, replies our interlocutor.

What symptoms does it cause?

This hormonal dysfunction causes symptoms that are expressed to different degrees depending on the woman. The most common are:

• Of recurring acne
• A accentuation of hairiness (hirsutism) in so-called male areas normally devoid of hair in women such as the face, chest, back, buttocks or the front of the thighs.
• A lack of rules or some very irregular periods

What is the origin of PCOS?

It is a complex syndrome whose exact origin remains unclear. Current research suggests it could all be at stake during intrauterine lifewith a fetal reprogramming leading to metabolic and ovarian disorders, often inseparable. However, PCOS manifests itself during puberty and does not completely disappear during menopause because metabolic disorders persist with sharp increase in risk of being overweight or even later diabetes. So, whether genetics plays a predisposing role In the triggering of this syndrome, epigenetics (the study of changes in gene activity) could be the key mechanism of PCOS as for many chronic pathologies. “This complexity around PCOS makes its communication and learning difficult for health professionals.“, would like to clarify our interlocutor.

Women are not infertile, but may have difficulty starting a pregnancy.

What are the consequences of PCOS?

“In addition to personal problems (we understand that no longer having periods can be worrying) and aesthetic problems (hair growth, recurrent acne), there is the problem linked to reproduction. Very often, PCOS is linked to delayed ovulation and therefore a delay in starting pregnancy“, he explains. Women are not sterile, but can have difficulty starting a pregnancy. Thus, “approximately 10% of women with PCOS have real difficulty achieving ovulation“, specifies the endocrinologist. However, the ovarian signs of PCOS are partly reversible and ” decrease over time to the extent that follicular capital decreases. Thus fertility also improves over time“, he continues. On the other hand, more than 2/3 of women with PCOS have a strong tendency to gain weight or even become overweight or obese and have an increased risk of diabetes and Dhigh blood pressurewhat is called metabolic syndromean important risk factor for cardiovascular illnesses (myocardial infarction, stroke, etc.). This could be explained by a genetic background (family history of overweight, obesity, high blood pressure, etc.)

When to consult for PCOS?

In front of theacne, menstrual cycle disorders, excessive hair growth or difficulty conceiving, a consultation with the attending physician, a gynecologist or a midwife is necessary.

In 2003, in Rotterdam, all the specialists in this syndrome met to establish the diagnostic criteria. To establish the diagnosis of PCOS, 2 of the 3 Rotterdam criteria retained must be met (in the absence of another disease associated with androgen excess (genetic adrenal disease or ovarian or adrenal tumors)):

1. Lack of rules or very irregular periods (every two months for example)
2. Hyperandrogenism clinical (excess hair in a masculine typography) and/or biological (increased testosterone level)
3. Multifollicular appearance of the ovaries (around twenty small follicles) with an increase in the size of the ovaries.

The diagnosis of polycystic ovarian syndrome can be complicated because it is a syndrome that evolves over time (a continuum of symptoms) and which, unlike most endocrine diseases, is not based on a binary approach. “North American studies, reproduced in France, estimate that women consult on average 4 to 5 times before being diagnosed with PCOS“, reports our expert. Generally, the diagnosis of PCOS is made by combining the results of the interrogation, ultrasound and those of laboratory examinations. The hormonal balance usually allows showing an increase in the circulating testosterone level and in a situation of desire for pregnancy an increase in pituitary luteinizing hormone (or LH) without elevation of the FSH. The ratio of these two hormones which orchestrate the normal ovarian cycle is essential for the proper maturation of the follicles. Too much LH facilitates androgen excess and blocked ovulation. Ultrasound allows it to detect the presence of multifollicles in the ovary. “In principle, endovaginal ultrasound is only done on a woman who has already had her first sexual intercourse.“, specifies our interlocutor. Thus, The diagnosis of PCOS during adolescence remains difficult.

On August 17, 2023, from new recommendations have been published by an international consortium of more than 3,000 professionals and led by the Australian University Monash. They revise the criteria for diagnostic of PCOS and advocate the dosage of anti-Müllerian hormone (AMH) as an alternative to ultrasound. In PCOS, AMH is two to three times higher than normal. “This is interesting, because a precise ultrasound with follicle counting is not always available, even in France” commented gynecologist and endocrinologist Catherine Azoulay in the Doctor’s daily. Furthermore, when irregular menstrual cycles and hyperandrogenism are present, ultrasound or AMH are not necessary for diagnosis. “In adolescents, both hyperandrogenism and ovulatory dysfunction are necessary but ultrasound and AMH measurement are not recommended due to low specificity” can we read in the guidelines published on the Monash University website.

What treatment is needed to treat PCOS?

Support depends on each case:

► Administration of natural progesterone can be prescribed to regulate the menstrual cycle. “Progesterone will reduce LH secretion and thus moderate hyperandrogenism, and often restore ovulation during subsequent cycles. After about ten days of treatment, progesterone stimulates the proliferation of the endometrium, which facilitates the implantation and development of the oocyte fertilized by a sperm. By restoring reproductive capacity, treatment with natural progesterone is the first recommended“, explains Professor Pugeat.

► Symptomatic treatmentparticularly to treat acne in the form of local creams or oral antibiotics is recommended. Recurrence of acne or hirsutism requires the use an anti-androgen combined with a treatment reducing ovarian androgen secretion. Cyproterone acetate (Androcur®) fulfilled this function. But the demonstration of an increased risk of cerebral meningioma associated with the dose and duration of prescription of this anti-androgen has considerably limited its use except in monitoring conditions, particularly by prescribing a brain MRI. In practice, “there is no specific treatment for hyperandrogenism. However, the anti-androgenic properties of spironolactone and its good long-term tolerance mean that it is widely used as an anti-androgen in the context of PCOS. This treatment can sometimes shorten menstrual cycles, hence the interest in combining it with taking progesterone. However, it has never benefited from a marketing authorization (AMM) in this indication in France.“, concludes Professor Pugeat.

► Treatment of metabolic syndrome must go through prevention, the adoption of healthy-dietary measures and weight control, particularly in women at risk (family history, overweight, etc.) during adolescence, in the event of pregnancy with an increased risk of gestational diabetes, then during menopause. Weight control and metabolic syndrome remain the major challenge of PCOS management. Its frequency and long-term risks mean that we are currently discussing the prescription of medications which are usually reserved for diabetes but which in the context of PCOS could prove effective in preventing it.

Thanks to Professor Michel Pugeat, professor emeritus, endocrinologist specializing in PCOS, co-author of “Le monde à l’ovaire”