The PCOS - Perimenopause Connection

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

The PCOS-Perimenopause Connection

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. But what happens to women with PCOS when they go through perimenopause and ovarian function declines? And what happens in post-menopause when they are no longer cycling at all?

Today’s article will explore these questions and more. Keep reading as we discuss if PCOS is over in perimenopause or if it’s a truly lifelong syndrome and what you need to know ahead of time so you can put support in place. We’ll cover:

• What is PCOS?
• Perimenopause
• PCOS in perimenopause
• Common PCOS and perimenopause symptoms
• Long-term PCOS risks
• PCOS action steps for women in perimenopause

What is PCOS?

PCOS is a syndrome, a collection of symptoms including irregular (or absent) menstrual cycles, elevated androgens (or symptoms of elevated androgens; testosterone is an androgen), and ovarian cysts. Over 80% of women with PCOS have insulin resistance, metabolic dysfunction characterized by elevated blood glucose and insulin levels, that increases the risk of weight gain, diabetes, and other chronic conditions.

Women with PCOS may experience fertility challenges and additional hormone imbalances, including estrogen dominance and low progesterone. Although we see these reproductive, metabolic, and hormonal imbalance trends in PCOS, it’s a highly individual condition. As PCOS presents differently among women, so does how PCOS responds to overall aging, and specifically ovarian aging, in perimenopause.

What is Perimenopause?

Perimenopause is the several-year or decade-long transition from reproduction to menopause, the one-year mark without a period. After menopause, women spend around 30% of their life post-menopausal.

In the early stages of perimenopause, women may experience higher estrogen levels, anovulatory cycles (cycles without ovulation), and lower progesterone levels. This hormonal picture may look similar to PCOS.

By later perimenopause, cycles become more irregular and farther apart. Estrogen levels decline, leading to metabolic changes, including insulin resistance, lipid imbalances, and inflammation. Post-menopausal women have an increased risk for hypertension (high blood pressure), metabolic syndrome, type 2 diabetes, and cancer. Women with PCOS also have a higher risk for metabolic disorders.

What Happens to PCOS in Perimenopause?

On one hand, PCOS symptoms may become worse through perimenopause, as women with metabolic dysfunction experience hormonal changes that increase risks even more. In other words, if you have insulin resistance as part of your PCOS profile, and perimenopause increases insulin resistance, you might be more prone to metabolic changes such as weight gain and increased abdominal fat. We’ll discuss the long-term risks more below.

On the other hand, perimenopause may offer a welcome PCOS reprieve as some women may find their irregular cycles become more regular and ovulatory in perimenopause. Over time, there is a reduction in follicles, which translates to fewer ovarian cysts. And for some women, the natural decline in testosterone production from the ovaries and adrenal glands that begins in the 30s may also lessen symptoms. As some women go through perimenopause, they may no longer meet the diagnostic criteria for PCOS.

Other research suggests that high testosterone levels may persist after menopause in some women. Integrative medicine can support either (or any) picture.

PCOS Vs. Perimenopause

PCOS and perimenopause may have several overlapping symptoms, making it challenging to know what’s what during this transition. Possible symptoms that may result from PCOS or perimenopause include:

• Acne and other skin issues
• Irregular or missed periods
• Headaches and migraines
• Sleep disturbances
• Hair loss on the head
• Unwanted hair growth on the face or chest
• Weight gain, especially around the midsection
• Fertility issues
• Mood changes

For women with PCOS, it may be challenging to distinguish PCOS symptoms from perimenopausal ones during this transition. However, a new PCOS diagnosis is unlikely during perimenopause as the onset of PCOS is typically with puberty. For women with no history of PCOS, the onset of one or more of these symptoms in their late 30s or 40s is more likely to be perimenopause. There are no diagnostic criteria for PCOS after menopause.

Long-Term Risks of PCOS

With aging and cessation of reproductive capacity, PCOS becomes more of a metabolic disorder vs. a reproductive one. Irregular cycles and menstrual cycle symptoms improve after menopause, but metabolic risk may persist. Women with PCOS often experience metabolic dysfunction and cardiovascular risk factors at an earlier age and are at increased risk of:

• Obesity
• Metabolic syndrome
• Type 2 diabetes
• Cardiovascular disease
• Sleep apnea
• Endometrial cancer
• Mood disorders
• Hypertension

The metabolic risk of PCOS is attributed to hormonal imbalances, insulin resistance, inflammation, genetics, and lifestyle factors. Women may enter perimenopause with other diagnoses besides PCOS, such as metabolic syndrome or prediabetes.

In general, a woman’s risk for metabolic disease increases in perimenopause and post-menopause with much lower estrogen on board. So, in theory, perimenopause can compound the risks for women with PCOS. A meta-analysis compared women with PCOS to BMI (body mass index)-matched controls without PCOS. One significant finding was that after menopause, women with PCOS had lower levels of protective HDL cholesterol.

Yet, some research suggests that metabolic and cardiovascular risk after menopause is about the same for women with and without PCOS. Another study suggests that the risks of PCOS after menopause may turn out to be lower than expected.

How to Support PCOS in Perimenopause

The bottom line is that many factors influence PCOS, and each woman may have her own experience and pathway through perimenopause. Aging may help some aspects of PCOS, but menopause is not a treatment for PCOS. Because of the increased metabolic and cardiovascular risks of both PCOS and perimenopause, it’s something women with PCOS need to stay on top of.

For those with PCOS, here are some action steps to take in the earliest stages of perimenopause or sooner to help mitigate the metabolic risks and protect your health moving forward.

1. Have regular health check-ups and monitoring with TārāMD. At least once per year, check key metabolic labs and other health markers. We can help alert you to any trends or changes and put action steps in place to course correct as needed. It’s much easier to prevent metabolic dysfunction than try to reverse it down the road.

2. Find and maintain a healthy weight. A healthy weight for you is individual and not necessarily based on your scale weight. A healthy weight means a balanced body composition and metabolic health. We can help you monitor and shift your body for long-term health. Read our article about PCOS and weight loss.

3. Discover personalized nutrition. While some nutrition foundations apply to everyone, including eating primarily whole foods and balancing blood sugar, it’s worth exploring to find the specific foods, meal timing, and other strategies that support your unique body, hormones, and health goals. Learn about the TārāMD nutrition team here.

4. Get moving. Metabolism changes in perimenopause and menopause regardless of PCOS status. Movement, including strength training, helps combat these metabolic changes. The best time to start is now. Read more here.

5. Commit to stress management. Stress makes every health issue worse, including PCOS and perimenopausal symptoms. It’s much easier to pop a pill or get a new biohacking device than to do the deep nervous system work that’s often required in midlife. While you’re at it, prioritize sleep, reduce toxins, and commit to radical self-care.

6. Use supplements and medications as needed. With a solid lifestyle foundation, supplements, herbs, and medications provide added support. Discuss bioidentical hormone replacement therapy in perimenopause (and beyond) with your TārāMD provider to see if it’s a good fit for you. Not only can it help manage perimenopausal symptoms, but it may offer some long-term protection against cardiovascular disease.

For women with PCOS entering perimenopause, it’s good to know your potential risks and take steps to protect your health through the hormonal transition. Lifestyle changes can be profound tools to support metabolic health and decrease hormonal symptoms, but they must be tailored to your PCOS picture. We have you covered at TārāMD with compassionate, comprehensive care!

References

1. Lenart-Lipińska, M., Matyjaszek-Matuszek, B., Woźniakowska, E., Solski, J., Tarach, J. S., & Paszkowski, T. (2014). Polycystic ovary syndrome: clinical implication in perimenopause. Przeglad menopauzalny = Menopause review, 13(6), 348–351.
2. Sharma, S., & Mahajan, N. (2021). Polycystic Ovarian Syndrome and Menopause in Forty Plus Women. Journal of mid-life health, 12(1), 3–7.
3. Helvaci, N., & Yildiz, B. O. (2022). The impact of ageing and menopause in women with polycystic ovary syndrome. Clinical endocrinology, 97(3), 371–382.
4. Millán-de-Meer, M., Luque-Ramírez, M., Nattero-Chávez, L., & Escobar-Morreale, H. F. (2023). PCOS during the menopausal transition and after menopause: a systematic review and meta-analysis. Human reproduction update, 29(6), 741–772.
5. Hodis, H. N., & Mack, W. J. (2022). Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing. Cancer journal (Sudbury, Mass.), 28(3), 208–223.