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InterNational Council on
Infertility Information Dissemination

Live from the PCOSupport Conference


What Happens to PCOS at Menopause and What You Can Do about It

by Christine M. Schroeder, Ph.D.

Presenter: Geoffrey Redmond, MD, The Women's Hormone Center, Cleveland, OH

Because of its effects on fertility, PCOS research has traditionally focused upon women of reproductive age. In recent years, however, more attention has been paid to the issue of PCOS as a long-term disorder. To this end, the role of PCOS in adolescence has, for example, been the subject of increased study. Less is known, however, about the other end of the spectrum - PCOS in menopausal women.

PCOS is a very individualized syndrome and treatment must therefore be determined by the individual patients' characteristics. The same is true for menopause and its side effects. The primary side effects of menopause are related to estrogen loss and the categories of effects include central nervous system (e.g., hot flashes), skin (thinning, elevated sensitivity), cardiovascular (increased risk of disease), genitourinary (negative effects on the bladder and vaginal area), and skeletal (reduction in bone density).

Traditionally, women's medicine has been biased towards reproductive function, i.e., issues that are not connect to reproduction are not considered as relevant are less likely to be studied. However, the effects of PCOS do not disappear with menopause, instead their manifestations simply change.

Studies have shown that elevations in androgen levels may moderate in menopausal PCOS patients; although their serum testosterone levels remain higher than non-PCOS controls, the levels themselves are still within normal range. However, not all androgen related effects will automatically moderate with the decrease in testosterone levels. Once activated by testosterone, for example, hair follicles do not become inactive upon the withdrawal of testosterone; as a result, hirsutism may persist in a pattern inconsistent with that of falling serum testosterone levels. Generally, however, hirsutism and acne will not worsen in menopausal PCOS patients; the incidence of alopecia, however, increases after menopause.

Traditional menopause treatment has focused upon prevention of cardiovascular disease and osteoporosis. Although PCOS patients are unlikely to be at increased risk for bone loss, their risk for cardiovascular disease is definitely higher than the risk for women without PCOS. This risk is rooted in a number of PCOS-related factors:

Elevated androgen levels
Poor lipid profiles
Obesity
Additionally, 40 percent of PCOS patients develop Type II diabetes by the age of 40, and diabetes is associated with a substantial increase in the risk of cardiovascular disease.

Because of this elevated risk, certain types of monitoring are particularly important in menopausal PCOS patients:

Screening for insulin resistance and diabetes, especially in obese patients and patients with a family history of diabetes.
Lipid profiles (LDL, HDL, ratios).
Blood pressure
Testosterone levels, if tests have shown them to be elevated.
The common common therapy for menopausal women is hormone replacement therapy (HRT). Although the main concerns of the medical community are reduction of risk for cardiovascular disease and osteoporosis, surveys have shown that menopausal patients considering HRT are most concerned about general feelings of well being, which seem to decrease with the onset of menopause, as many women experience significant mood deficits in the presence of falling estrogen levels.

There is no evidence that PCOS patients respond to HRT differently than non-PCOS patients. This issue has not, however, been well-studied, so few conclusions can be drawn on this issue as of now.

One final concern for PCOS patient management is the increased risk of endometrial cancer which may occur as the result of prolonged unopposed estrogen simulation. For this reason, it may be especially important for PCOS patients to use an HRT method that allows for the regular progesterone-induced shedding of the uterine lining shedding. Patients generally have a much more positive experience with a micronized progesterone, such as Prometrium, compared to a synthetic progestin, such as Provera. Androgenic progesterones, such as levonorgesterel should be avoided.

The presenter also cautions against the recent enthusiasm for giving patients "testosterone replacement therapy" with the goal of increasing women's libido. He argues that there is no research evidence to support the need for testosterone replacement and that such therapy might be particularly detrimental in the case of PCOS patients, who already have issues with long-term elevated androgens.

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