PCOS Part 3: The Part Where I Don’t Get a Cycle for 4 Months is Great, It’s When I Bleed for 2 Months That I Have A Problem

What do the average PCOS periods look like? Trick question because there is no such thing. What happens to alot of women is that they will go 2-6 months without getting a period and then bleed for 5-60 days. It’s completely unpredictable and what happened this month won’t be the same next year. So, what creates this pattern? The answer is generally not ovulation.

So, for the women with PCOS who are maintaining a healthy body weight and eating a low carb diet and therefore getting a cycle at a roughly predictable interval - maybe 30-40 days, they probably are ovulating and thus the cycle comes because of the fall off in hormones that happens when conception doesn’t occur. It’s the other group that we are more focused on. So, FSH is produced, which in turn causes the production of follicles and therefore estrogen. Because this system isn’t well regulated and the LH surge that causes ovulation doesn’t work the way it should, these women never progress to full follicle maturity that results in ovulation and then gets the follicle (or corpus luteum as we would now call it) to make progesterone. So, because you keep chronic low estrogen and don’t have adequate progesterone production, the lining of the uterus is constantly being stimulated. That stimulation makes the lining grow and grow. Were progesterone present, it would stabilize the lining and stop it from growing any further. If the progesterone never comes, there is never the stabilization step.

So, the lining is growing and growing, but the lining doesn’t have an unlimited ability to grow. It will eventually outgrow it’s blood supply and that’s when you start bleeding. In a period, your whole lining sheds and you bleed during this process, but then your body ramps up and starts making more estrogen to stop the bleeding and regenerate the lining. In our PCOS example, only parts of the lining are breaking down and shedding, but there are other parts that are still going along fine and because you aren’t going into a new cycle, there is nothing to stop the bleeding, so you just bleed and bleed and bleed. Over a long enough time, you will find that the lining then starts to become unusual and can change into endometrial hyperplasia or endometrial cancer. Hyperplasia is pretty common, cancer is much less common, but there are things wer can do to prevent this from happening.

So, how do we control the bleeding and prevent the lining from becoming cancerous?

We can use progesterone supplementation at regular intervals - this often looks like 10 days a month of provera or nowadays prometrium.

we can use a birth control pill that keeps the lining thin all the time.

We can use direct endometrial progesterone supplementation with an IUD.

We can use an endometrial ablation.

Obviously, only one of these allows for the possibility of pregnancy and is consistent with those who desire to avoid birth control for personal or religious reasons (hint, its the first one). And, they pretty obviously all involved medication use. There is also the option of a no carb diet and weight loss and since a 10-20% weight loss is very likely to trigger the onset of ovulation, it’s not a bad metod to try.

We can also use things like lysteda to turn off the bleeding when it’s been going on for forever or so bad that you become anemic, but it doesn’t do anything to lower the cancer risk, which is why it isn’t my favorite in this situation.

Finally, if you are over 30 and get a sudden increase in heavy bleeding and have PCOS, it’s not a bad idea to do an endometrial biopsy to make sure everything is ok (or do a HSC D&C to make sure there are no polyps and reset the lining). The youngest patient I’ve seen endometrial cancer in is 26, so my threshold for worriying about this is very low and if anything too crazy is happening, a biopsy is easy to get.

Generally, the main point I want to make is that it’s important to not just let this ride. If you have the bleeding pattern described in the title, we should do somthing to manage that.