Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects approximately 5-10% of reproductive-aged women. PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. One of the main concerns for women with PCOS is whether it will affect their experience of menopause. In this article, we will explore the current evidence on whether menopause is delayed in women with PCOS.
What is PCOS?
PCOS is a heterogeneous condition that is defined by two of the following three criteria:
- Oligo-ovulation or anovulation – Irregular or absent ovulation
- Hyperandrogenism – Elevated levels of androgens (male hormones) such as testosterone or clinical manifestations of high androgens like hirsutism, acne, and alopecia
- Polycystic ovarian morphology on ultrasound – Enlarged ovaries with 12 or more follicles measuring 2-9mm in diameter
The most common symptoms of PCOS include irregular menstrual cycles, infertility, hirsutism, acne, alopecia, and obesity. PCOS is also associated with metabolic disturbances like insulin resistance, diabetes, dyslipidemia, and increased risk of cardiovascular disease.
While the exact cause of PCOS is still unknown, it is thought to be linked to a combination of genetic, metabolic, and environmental factors that lead to hormonal imbalances and ovarian dysfunction. Diagnosis is made based on the Rotterdam criteria of hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Treatment focuses on management of symptoms and aims to regulate menstrual cycles, treat hirsutism/acne, restore fertility, and reduce metabolic complications.
What is menopause?
Menopause refers to the permanent cessation of menstrual cycles and fertility due to loss of ovarian function. It usually occurs naturally between the ages of 45-55 years. Menopause is diagnosed after a woman has gone 12 consecutive months without a menstrual period. The period leading up to menopause is called the menopausal transition or perimenopause, which can last up to 10 years.
During perimenopause, women experience irregular menstrual cycles, hot flashes, mood changes, vaginal dryness, and fluctuating hormone levels as ovulation becomes more infrequent. Natural menopause occurs due to the age-related depletion of ovarian follicles. When the ovaries run out of follicles, they no longer produce adequate estrogen and progesterone, leading to infertility and irregular cycles.
On average, the age of natural menopause is around 51 years old. However, menopause can occur earlier or later than the typical age range for some women. Early menopause refers to menopause occurring before age 45, while late menopause occurs after age 55. A variety of factors can influence when a woman experiences menopause, which leads to the question of whether PCOS affects age at menopause.
Does PCOS delay the onset of menopause?
There has been ongoing debate around whether having PCOS can delay the onset of menopause compared to women without PCOS. Some key points on this topic:
- Several studies have found that women with PCOS tend to experience menopause 1-2 years later on average compared to women without PCOS.
- A meta-analysis of 10 studies with over 13,000 women found that those with PCOS underwent menopause on average 1 year later than women without PCOS.
- The difference in age of menopause has ranged from 0.5 years later up to a delay of 2-3 years in some studies.
- However, other studies have found no difference in age at menopause between women with and without PCOS.
Overall, current evidence suggests there may be a slight delay in onset of menopause for women with PCOS, but findings are inconsistent across studies. The 1-2 year average delay found is unlikely to be clinically significant for most women.
Possible reasons for delayed menopause in PCOS
There are several theories as to why menopause could potentially be delayed in some women with PCOS:
- Higher AMH levels – Women with PCOS tend to have higher anti-Mullerian hormone (AMH) levels throughout their reproductive years compared to women without PCOS. As AMH reflects ovarian reserve, higher levels may indicate more follicles remaining as a woman approaches menopausal age.
- Higher antral follicle count – Studies show women with PCOS have 20-30% more antral follicles counted on ultrasound compared to age-matched controls. Again, this higher follicle count may translate to a slightly prolonged fertility and menstrual function.
- Androgen excess – Increased androgen levels associated with PCOS could help maintain ovarian function for a longer period.
- Obesity – Up to 80% of women with PCOS are overweight or obese. Higher BMI is linked to later menopause, so for those with PCOS and obesity, the extra weight may contribute to delaying menopause.
However, more research is needed to confirm if any of these factors definitively impact menopausal timing in PCOS.
Does PCOS affect menopausal symptoms?
Along with potentially altering the onset of menopause, there has also been some research looking at whether having PCOS affects a woman’s experience of menopausal symptoms. Key findings include:
- Multiple studies report that women with PCOS undergo the menopausal transition with fewer vasomotor symptoms like hot flashes and night sweats compared to non-PCOS women.
- This reduction in vasomotor symptoms may be attributed to higher androgen levels in PCOS providing some protection against estrogen fluctuations.
- However, women with PCOS do not appear to have less urogenital symptoms like vaginal dryness during menopause.
- Research on psychosocial symptoms like mood changes is less consistent, with some studies finding no difference and others reporting women with PCOS have more anxiety and depression symptoms during the transition.
- Use of anti-androgen medications like spironolactone in PCOS may diminish protective effects against vasomotor symptoms.
Overall, women with PCOS may undergo the menopausal transition and early menopause with fewer hot flashes and night sweats. However, more research is still needed in this area focusing on quality of life and specific PCOS phenotypes.
Does PCOS increase health risks after menopause?
While the data on menopausal timing and symptoms is still inconclusive, one significant consideration is whether having PCOS earlier in life impacts a woman’s postmenopausal health. Some of the key health concerns include:
Women with PCOS have increased risk of diabetes, high blood pressure, and dyslipidemia – all major risk factors for cardiovascular disease. This predisposes women with PCOS to higher rates of heart disease events and stroke after menopause if metabolic features are left untreated. Lifestyle management of obesity, glycemic control, and hypertension is imperative.
Chronic anovulation and estrogen imbalance in PCOS leads to increased risk of abnormal endometrial hyperplasia and endometrial cancer. However, this risk is significantly reduced if menopause occurs at an average age. Still, any abnormal uterine bleeding after menopause needs prompt investigation in women with PCOS history.
Diabetes and metabolic syndrome
Insulin resistance is highly prevalent in PCOS, making diabetes and metabolic syndrome major concerns that often persist after menopause. Continued monitoring and prevention of cardiometabolic disorders is essential.
Mental health disorders
Higher rates of anxiety, depression and reduced quality of life are reported in women with PCOS – issues that may continue after menopause. Assessment of mood disorders and support is important.
Overall, PCOS-related reproductive and metabolic abnormalities can impact long-term health. A multidisciplinary approach is key for minimizing complications beyond menopause.
Treatment considerations for menopausal transition in PCOS
For women approaching menopause with pre-existing PCOS, there are some unique treatment considerations:
- Combined hormonal contraceptives are typically discontinued 1-2 years before anticipated menopause to allow resumption of natural cycles.
- Estrogen-based hormone replacement therapy may help reduce menopausal symptoms but effects on cardiovascular health need evaluation.
- Symptoms like hot flashes may start earlier in the menopausal transition due to prior estrogen exposure from OCPs.
- Anti-androgens like spironolactone for hirsutism can be continued but may unmask vasomotor symptoms.
- PCOS-related metabolic comorbidities need ongoing monitoring and management throughout and beyond menopause.
- Vaginal dryness, urinary symptoms, sexual dysfunction should be treated as they persist despite PCOS status.
- Routine cancer screening including pap smears and mammograms remain important after menopause.
- Bone density screening for premature ovarian failure or osteopenia is recommended.
Individualized treatment plans are necessary for women with PCOS reaching menopause that account for their reproductive and metabolic features.
Can PCOS cause primary ovarian insufficiency?
Primary ovarian insufficiency, or POI, refers to loss of normal ovarian function before age 40. This can cause menopause to occur 5-10 years earlier than average. Studies show approximately 4-8% of women with PCOS also have POI, a rate higher than the general population.
The causes of POI in PCOS are still unclear. Potential contributing factors include:
- Genetics – Chromosomal defects can underlie both POI and PCOS.
- Autoimmune conditions – Some women with PCOS have anti-ovarian antibodies that may promote follicular atresia.
- Chronic inflammatory state – Low-grade inflammation associated with PCOS and insulin resistance may have destructive effects on ovarian function over time.
- Oxidative stress – Both conditions feature high levels of reactive oxygen species that can damage oocytes and speed up follicular depletion.
- Iatrogenic factors – Ovarian surgery or radioactive treatments for other conditions increase POI risk later.
More research is needed to elucidate the overlap between PCOS and POI. Women with PCOS diagnosed with POI require appropriate hormone replacement therapy as well as counseling on early menopause.
In summary, current evidence suggests:
- Women with PCOS may experience menopause about 1-2 years later than average.
- Higher AMH levels, antral follicle count, and androgen excess may contribute to slight menopausal delay in PCOS.
- Women with PCOS report fewer hot flashes during menopausal transition but mood symptoms are inconsistently described.
- Cardiovascular and metabolic complications need continued management for PCOS patients after menopause.
- 4-8% of women with PCOS suffer from premature ovarian insufficiency leading to early menopause.
- Individualized treatment plans are important when addressing menopause in women with PCOS.
- Further large studies are still needed on precise menopausal timing and long-term health outcomes.
While a modest delay in menopause may occur for women with PCOS, optimal symptom management and reducing long-term health risks remain the most crucial priorities during this transition period and beyond. Continued research will help clarify the interactions between PCOS and menopausal health.