If you have PCOS you may be wondering how things will shift as you transition through perimenopause and into menopause when estrogen and progesterone fall. You may also wonder how testosterone fits into an HRT plan or your midlife journey given that you have been higher androgen thus far. And you may have been told the menopause “cures” PCOS which actually couldn’t be farther from the truth.
In fact, women with PCOS have already been enduring much of the fallout from low estrogen and low progesterone, high inflammation, oxidative stress and insulin resistance for years when they enter perimenopause and into menopause. It makes PCOS related risk factors even greater for things like heart disease and stroke and it might make things like weight loss an even bigger challenge.
Terrible, I know. But the good news is there are some aspects of PCOS that do make the perimenopause transition a bit easier and those key diet and lifestyle things that work during midlife can still work for women with PCOS – we just have to generally double down on our commitment to them.
Why Menopause Won’t Fix PCOS
The misunderstanding that PCOS is simply a period problem or that it merely impacts a woman’s fertility is likely where this menopause or hysterectomy can cure PCOS idea came from. However, while the impact of PCOS might show up in the ovaries it’s not an issue isolated to the our reproductive organs but rather a metabolic and inflammatory disorder thus it impacts a woman’s entire physiology.
This idea that PCOS only is important in the fertility conversation is an unfortunate underestimation of the true nature of PCOS. It is a complex condition that extends well past not ovulating well and not able to get pregnant as easily. There is dysfunction in adipose tissue (fat cells), a tendency towards high inflammation, insulin resistance and androgen excess. It’s associated with diabetes, non-alcoholic fatty liver, autoimmune issues and cardiovascular disease.
Understanding how PCOS is bigger than a period problem will help you see that menopause will not fix or “cure” PCOS, in fact women with PCOS have a few things stacked against them when it comes to perimenopause and menopause. But there’s a few advantages too!
A New Understanding of PCOS
PCOS has long been described as a condition of androgen excess. Elevated testosterone (sometimes elevated DHEA as well) leads to many symptoms such as acne, hirsutism (daker, coarser body hair on face, abdomen, etc.) and androgenic alopecia (hair loss at crown or temples) as well as hallmark issues of faulty ovulation, irregular or absent menstrual cycles and possibly infertility. From this perspective, it would make sense that the hormone decline of menopause, which includes lowering of androgens, would alleviate these symptoms but the truth is that while elevated testosterone is a diagnostic criteria, it’s not a root cause of PCOS.
In women, testosterone is produced largely as a precursor to our main sex hormone: estradiol. Women with PCOS will have lower or improperly cycling levels of estradiol due to a defect in the enzyme that makes this conversion from testosterone to estrogen conversion known as aromatase.
Aromatase is located in the ovaries and other place such as body fat and when it doesn’t work properly, testosterone will build up and estrogen will remain low. Estradiol is the Queen Bee of female physiology and we have receptors for it throughout our bodies, well beyond our uterus and breasts. Estrogen receptors are found the gut, the heart and our blood vessels, our neurological system and brain, the immune system and of course our skin, bones and muscles.
It’s the lack of proper estrogen that leads to the inflammation and metabolic dysfunctions of PCOS such as insulin resistance. We know as well that it’s the lack of estrogen that creates an increased risk of all cause mortality in women after menopause including heart disease, stroke, diabetes, fracture, dementia, etc.
Perimenopausal Hormone Shifts For Women With PCOS
Estrogen is on the decline during perimenopause and women with PCOS enter this phase already lower estrogen overall due to those faulty, PCOS follicles on the ovaries.
Women with PCOS have often spent decades in a lower or irregular estrogen state that leads to more metabolic dysfunction, more inflammation, worse cardiac health, a more difficult time losing body fat and a harder time managing blood sugar. As well this low estrogen creates more depression and more brain fog, both major symptoms of perimenopause and menopause.
All women will start to see lower progesterone levels as early as our late 30s and certainly into our 40s as ovulation becomes less efficient but many women with PCOS are already experiencing ovulation issues, less frequent periods and lower progesterone because of it. This can create issues with fertility of course, but also leading to more anxiety and mood issues, trouble with sleep and handling stress.
Testosterone on the other hand, may be more confusing during midlife for women with PCOS. Elevated androgens, DHEA or testosterone is a facet of PCOS during our teens, 20s and 30s and when women without PCOS enter their 40s they are often seeing a decline in testosterone.
However not every woman will need testosterone replacements, during midlife especially some women have normal and even elevated testosterone. Read more in this article.
Women with PCOS might very well have elevated or normal testosterone during perimenopause and into menopause but they may feel the effects of any drop in testosterone more profoundly, even if it’s not showing as very low on lab testing, as they are used having more androgen around.
What the Perimenopause Hormone Landscape Means for PCOS
Here’s the disappointing news: the struggles of perimenopause are generally hard for women with PCOS. I’m sorry, believe me I am right there with you for this.
It’s not hopeless, not at all, but like so many other struggles with PCOS such as fertility or weight loss, some things are just harder for us.
We come into midlife already with more inflammation, more oxidative stress, more mood issues, often a harder time losing weight, more difficulty sleeping and worse circadian rhythms, worse blood sugar control and insulin resistance, more stress sensitive and more hormone dysregulation across the board. All that, each of those things, are hallmarks of the hormone changes that come with perimenopause.
Women who have learned how to eat, exercise and live for their PCOS will do better during midlife than those who haven’t, but it’s still a bit harder for us because often women with PCOS come to midlife with:
With years of being lower estrogen we are already at risk for lower bone density, worse heart health and more metabolic issues like insulin resistance, higher lipids, higher blood pressure, etc.
We also have often more fatigue and worse mitochondrial health due to longer term low estrogen as well.
Years of having lower progesterone from not ovulating optimally can make us more anxious, have more insomnia and struggle to tolerate stress.
While we have very little research on how women with PCOS specifically fair during perimenopause and menopause, we have plenty of clinical experience from experts like myself who see with these women in practice every day .
And many PCOS experts also have PCOS so they are living it right along with you. It’s hard, but again, it’s not hopeless.
It does mean though that all the advice out there for perimenopausal women applies to us ten fold:
- Lift weights
- Eat a high protein and high produce (veggie) diet
- Walk a ton
- Utilize key supplements to support metabolism, sleep and lower inflammation
- Have a healthy gut microbiome
- Life a low inflammatory lifestyle (low alcohol, plenty of sleep, plant heavy diet)
- Keep your blood sugar balanced
I talk more about what to eat during perimenopause in this article.
That might feel disappointing or like it’s a tough battle to fight, but don’t forget women with PCOS have gotten through some very tough stuff by the time we reach midlife.
Many of us have faced a lifelong battle with body image and weight loss; struggled with embarrassing symptoms like acne, hair loss or unwanted hair growth on our face, abdomen, etc.; and many of us have endured a host of fertility challenges including our increased risk for miscarriage. We are strong, we’ve gotten through worse than menopause. Remember that.
And it’s not all gloom and doom, read on…
Interesting Ways Women With PCOS Can Actually Do Better In Perimenopause
More Fertile
It might be a pro or a con depending on your desire to get pregnant, but fertility can actually increase during perimenopause for women with PCOS. So if you’re still open to a baby, your chance might actually go up in midlife whereas most women’s fertility goes down in their 40s.
Research has shown that women with PCOS hit their fertile peak 2-4 years later than women without PCOS due to higher levels of androgens and higher Antimullerian hormone (know as AMH, a marker of ovarian reserve).
Higher Androgens
Because women with PCOS come into midlife with elevated or at least normal levels of testosterone during midlife, we have some advantages when it comes to keeping and building lean muscle mass, libido, mood and bone health. We still often metabolize it poorly and make too many troublesome androgen metabolites so we still need to watch our blood sugar and take nutrients like these to avoid breakouts, hair loss, etc.
While testosterone usually gets all the press, women actually have several other androgens including DHEA, DHEA-S, androstenedione and androstenediol. Women with PCOS generally have higher circulating levels of these androgens than women without PCOS.
And while testosterone can decline in women during midlife it doesn’t always (which is why it needs to be tested before initiating therapy, see more in this article) and research has shown (the SWAN study) that most women experience a rise in other androgens: DHEA, DHEA-S, Androstenedione and Androstenediol starting in early perimenopause and stay elevated until about 2 years after menopause.
Androstenediol is androgen that’s rarely talked about and it has both androgenic and estrogenic activities and is secreted along with DHEAS and DHEA during the menopausal transition. This may play an important role in protecting women from low estrogen as perimenopause starts. During this time concentration of Androstenediol concentrations can be 100 times the average estradiol levels.
Though a weaker estrogenic response than estradiol, women with PCOS having higher levels of androstendiol can see some protection from estrogen loss. Offering protection as well from loss of muscle and bone, and less loss of cognitive function as they go through perimenopause and menopause. There seems to be benefit specifically to brain and skin which means less brain fog and less loss of skin elasticity – that’s a win!
PCOS + HRT
Because women with PCOS will feel the effects of midlife as bad or worse as your average woman, HRT can be a real support for their metabolism, managing inflammation, weight loss, etc.. There are a few unique considerations though as PCOS women have some unique issues when it comes to processing our hormones and there does need to be some extra considerations for balancing estrogen and testosterone.
Many women with PCOS will still struggle with higher androgen symptoms like darker coarser hair growth and breakouts if they use testosterone because they are often more sensitive to androgens so we need to proceed with a lot of caution when using testosterone or DHEA to avoid unwanted side effects.
I cover testosterone replacement in this article and my own experience with using DHEA and testosterone during perimenopause here. It’s not always an absolute no go but it warrants a very thoughtful approach.
As I tell all my patients when discussing HRT: it’s not the end all be all. HRT can be a super helpful tool during midlife and certainly for women with PCOS during midlife, but we still need to tend to other sources of inflammation, gut health, blood sugar balance and get in those weights and those walks.
This is precisely what I do in my practice, so reach out if you need me!
And I cover ALLLLL of the many things that HRT doesn’t necessairily help with in this FREE guide: Midlife Is More Than HRT. If you’re struggling to feel empowered or midlife and perimenopause have you out of sorts this guide will help!