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PCOS after Menopause

Blog written by Dr Nitu Bajekal, Senior Consultant ObGyn and Co-Author of ‘Living PCOS Free‘.

I wrote Living PCOS Free with my daughter Rohini, a nutritionist, as I am extremely passionate about empowering those with PCOS to live long, healthy and happy lives. This practical guide will show you how to successfully manage your condition using proven lifestyle approaches alongside western medicine. Raising awareness of what to look out for allows those with PCOS who are going through perimenopause and menopause to access early help, support and advice. This may be through campaigns such as this month’s Menopause Awareness Month, workshops and education in workplaces or even by opening up the conversation between friends, family and colleagues. It’s never too early – or too late – to start.

What is PCOS?

PCOS is a complex condition that affects the way the ovaries function, resulting in a wide range of reproductive, metabolic and psychological symptoms. The exact cause of PCOS is unknown, although insulin resistance, when insulin levels rise as tissues become resistant to the action of insulin, is considered to be a main driver of the condition and many of the common symptoms.

Despite PCOS being the most common endocrine condition to affect women and those AFAB (assigned female at birth), with at least 1 in 10 affected, most people have never heard of it. Depending on how hard one looks for the condition, up to 3 in 4 of those with PCOS remain undiagnosed.

What are the common symptoms of PCOS?

Infrequent periods or missed periods are the most common sign of PCOS (oligomenorrhoea/amenorrhoea). It’s important to note that pain is not a feature of PCOS and other coincidental causes such as endometriosis should be considered.

  • Excess facial/body hair (hirsutism)
  • Acne (often adult and/or cystic)
  • Scalp hair loss (alopecia)
  • Excess weight gain
  • Insulin resistance
  • Fertility problems (PCOS is the leading cause of anovulatory infertility)

There are several less well-known symptoms including:

Eating disorders, especially binge eating disorders without purging, unlike bulimia. This may be missed, especially in those from different ethnic groups, LGBTQ+ or those with excess weight.

  • Excessive daytime sleepiness
  • Breathing problems (sleep apnoea, snoring)
  • Acanthosis nigricans (darkened skin: behind the neck, underarms, groin).
  • Psychological issues such as depression, anxiety and OCD

How does the condition change as a woman approaches menopause?

In my new book, Living PCOS Free, I dedicate an entire chapter to the topic of menopause in PCOS as this condition does affect how women and AFAB people experience this crucial phase of life.

There has been little scientific research on how PCOS affects the menopause or the lead up to it and more studies are urgently needed. The criteria to diagnose PCOS (Rotterdam criteria) change in the menopause as periods stop, so irregular periods cannot be used as a criterion.

How can women distinguish between PCOS and perimenopause symptoms?

The perimenopause can last from 2 to 8 years (the average is 4 years) and is the lead up to menopause. The perimenopause is a time, often in one’s early 40s, when women and those AFAB may notice hormonal fluctuations, period irregularities and mood changes. As a result, there can be a lot of overlap with symptoms of PCOS and perimenopause, such as female-pattern hair loss and anxiety.

If you have never been diagnosed with PCOS, a long history of irregular cycles or anovulatory subfertility may help give your doctor a clue.

Do PCOS symptoms change after menopause?

A common symptom in PCOS, acne, is actually reported by 15% of all women over the age of 50 so it is difficult to work out how exactly PCOS symptoms change after menopause. Even without PCOS, women going through menopause experience issues such as anxiety, female-pattern hair loss and excess hair growth – all common symptoms in PCOS.

Are androgen levels still high through the transition?

Androgen excess symptoms seem to persist in menopause for those with PCOS. In particular, increased hair growth (hirsutism) and risks of hypertension (high blood pressure), high blood sugars and blood lipids are higher than in those without PCOS. This indicates that it is especially important to make lifestyle changes early, which I discuss in detail in Living PCOS Free.

Is there anything different that a woman should expect as she goes through menopause if she had PCOS in the past? Any symptoms that may be more or less severe?

Menopause appears to be delayed by two years in women with PCOS, and periods seem to become more regular after the age of 40. Women with PCOS also appear to have fewer hot flushes than those without PCOS. Other PCOS symptoms, such as excess hair growth or scalp hair loss, may continue to persist.

Are there any treatments or lifestyle changes a woman should be aware of as she goes through menopause with PCOS?

It is important to be mindful of the long-term risks of PCOS and bring in lifestyle changes as early as possible. Women now often live 30 years after their menopause and this period of their lives is extremely important. The average life expectancy in the UK is around 81 years.

Information is key, as myths and misinformation can prevent women from accessing both lifestyle and nutritional support. For example, strength training can reduce osteoporosis, and eating soya foods such as tofu is safe and particularly healthy for menopausal women as they are a rich source of healthy plant oestrogens. Life-improving formal hormone replacement therapy (HRT) may also help. Women can be safely advised to use HRT after discussion of the very small risks rather than relying on expensive supplements that have unproven and sometimes serious unwanted side effects. Always rely on reliable and credible evidenced based health resources (NHS, RCOG, Verity, www.nitubajekal.com).

PCOS is a chronic condition so, while there is no ‘cure’, making positive lifestyle changes can go a long way in managing it and its symptoms in the menopause and beyond, including insulin resistance, both in the short  and longer term. Lifestyle modifications can tackle the underlying insulin resistance. In fact, national and international guidelines recommend lifestyle and behavioural changes as the first line of management for PCOS, even before medications. This is important given the higher risk of other health conditions if you have PCOS (type 2 diabetes, womb cancer, cardiovascular disease etc).

Here are some lifestyle changes that are helpful for those going through menopause with PCOS:

Adopt a plant-predominant dietary pattern
People with PCOS should be advised to focus on predominantly whole plant foods, including whole grains, beans, fruit, vegetables, nuts and seeds, herbs and spices. These foods are full of fibre and micronutrients that are nourishing and absorbed slowly, helping to normalise blood sugars. We know this works very well in people with type 2 diabetes and metabolic syndrome as well as reducing excess weight gain reported as one gets older. Crowd out trans fats, oils, junk and ultra-processed foods, sugar-sweetened drinks, fruit juices and sugary foods such as cakes and biscuits which promote oxidative stress and inflammation. Limit barbecued and fried foods and ultra-processed foods that are high in tissue-damaging advanced glycation end products (AGEs) which are linked to ageing, heart disease and infertility. Vitamin D deficiency is common in women and those AFAB with PCOS, and there is some evidence that vitamin D supplementation after an initial blood test to measure levels may improve insulin sensitivity.

Move your body regularly
Regular movement in a form that you enjoy is key. Aerobic exercise and resistance training (including high intensity interval training (HIIT) in short bursts) are all recommended to help improve insulin sensitivity in women with PCOS. Aim for 300 minutes of exercise per week (approximately one hour a day) and try to exercise outdoors in natural light to boost your mood. Physical movement and exercise are also immensely helpful in improving tissue sensitivity to insulin, especially when undertaken after meals to dampen blood sugar swings.

Prioritise sleep
Ensure a regular sleep routine with seven to nine hours of restorative sleep.

Find a way to de-stress and relax
Consider exercise, spending time in nature, meditation, mindfulness, community work, psychotherapy or yoga to help manage stress and lower cortisol levels which make insulin resistance worse.

Foster positive social connections
Build or join a community, whether online or offline; ensure you have a support network or a friend you can trust and confide in. Loneliness, which is more common as we get older, is a source of chronic stress and is associated with an increased risk of heart disease, high blood pressure, Alzheimer’s disease and type 2 diabetes.

Avoid or limit risky substances
Eliminate risky substances such as drugs and tobacco and limit alcohol (people with PCOS are at higher risk of non-alcoholic fatty liver disease), as these offer no health benefits.

 

Visit https://nitubajekal.com/menopause/ for more information as well as nutrition advice https://nitubajekal.com/menopause-nutrition-advice/

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Author Q&A: Rohini Bajekal, co-author of ‘Living PCOS Free’

book display

Over the last few years, there has been a shift in narrative about women’s health, especially topics surrounding reproductive health. Renowned MD Obstetrician-Gynaecologist Dr Nitu Bajekal who has decades of experience in this field has worked with her daughter, expert nutritionist, Rohini Bajekal on the much-anticipated book ‘Living PCOS Free’. The book is all about Polycystic Ovarian Syndrome. PCOS is one of the most common endocrine disorders worldwide, which affects at least one in ten women or anyone assigned female at birth. Hammersmith Health Books is proud to be publishing this book, which aims to give those going through PCOS an insightful and inspirational guide. This blog is written by Rohini Bajekal, who gives a personal account of why she worked with her mother and co-author to write the book and what they hope to achieve with it.

‘Living PCOS Free’ launches on 28th April and can be purchased here.

What spurred you to write ‘Living PCOS Free’?

They always say you write the book you wish you had on your bookshelf. As Rohini had personal experience of Polycystic Ovary Syndrome (PCOS) and Nitu has 35 years of experience helping patients, we both had a clear vision for our first book together. We had never come across a book on PCOS written by qualified health professionals that highlighted proven lifestyle approaches alongside western medicine and felt that this needed to be addressed as soon as possible. Nitu had wished to write a book for years but it took a pandemic and several lockdowns to be able to carve out the time to sit down and write it together. The initial idea was to write a general women’s health book but Rohini felt that since Nitu is an ObGyn, a general book would not do justice to the complex nature of these conditions as we would only be able to dedicate a few pages to each condition such as fibroids, endometriosis, painful periods etc. and that would not really help people to address their issues.

Could you tell us a bit more as to why PCOS is more than a fertility issue?

PCOS is often simplified as purely a fertility issue as it is the leading cause of infertility worldwide. However, PCOS and its other short-term and long-term complications are woefully underrepresented both in scientific research and mainstream conversations. It is estimated that as many as three-quarters of those living with PCOS remain undiagnosed.

PCOS is a complex condition that affects the way the ovaries function, resulting in a wide range of reproductive, metabolic, and psychological symptoms that affect women differently.  Societal stigma (due to patriarchal beauty standards) often associated with common symptoms, such as weight gain, scalp hair loss, acne, irregular periods and excess hair growth, means many women are unable to talk about it openly or seek the help they deserve.

In addition, many women are told that losing weight is the only solution to improving their PCOS with little guidance or support on how to follow a “healthy lifestyle”. In fact, 20% of those with PCOS have lean PCOS and are within the “healthy” BMI range, yet still struggle with the symptoms.

As people with PCOS have a higher risk of endometrial cancer, type 2 diabetes, heart disease and other long-term chronic conditions, it is critical to introduce sustainable nutrition and lifestyle changes as early as possible. All national and international guidelines recommend lifestyle interventions to be the first line of management for PCOS, even before medications. PCOS is a condition that is heavily influenced by our lifestyle — how we eat, sleep, move, stress, interact and so on. The book is packed with information on how to make lifestyle changes, including following a plant-based diet pattern, moving regularly, managing stress, getting restful sleep, nurturing positive social relationships and avoiding use of risky substances such as tobacco and alcohol.

What do you both hope to achieve with the book in terms of awareness and change for those suffering from PCOS?

Our hope is to reach anyone living with PCOS, a complex condition that does not receive the attention it deserves. We especially want to reach those from marginalised communities, including people of colour who are not always able to access the best medical care and support for a number of reasons that we discuss in the book. We have tried to be inclusive as PCOS also affects trans men and non-binary folk. We also hope that family members, partners and friends of those living with PCOS read this book to better understand it and to support the person they care about. Since a staggering 75% of people with PCOS remain undiagnosed, we also hope to reach those struggling with the symptoms such as fertility issues, irregular periods or excess hair growth, but for whom the dots have not yet been joined.

Advocating for PCOS is political and we hope this book is a stepping stone for greater change and awareness around reproductive health. The economic burden of PCOS was previously estimated at approximately $3.7 billion annually in 2020. Even more strikingly, this figure only considers the costs of the initial diagnosis and of reproductive endocrine morbidities, without considering the costs of pregnancy-related and long-term morbidities.

We know that ‘Pinterest’ is about to release a trend report which shows that searches for menstrual cycle are up as younger people wish to empower themselves with knowledge about their cycle – how do you feel about this and how it links in with your work?

We think it is so promising that young people are empowering themselves with knowledge and raising awareness of what a normal menstrual cycle is. Dr Nitu Bajekal is active on TikTok where there are a lot of menstrual educators creating content. We bust a lot of myths in Living PCOS Free around menstruation – we even talk about menstruation in non-human animals! So many people who menstruate struggle with irregular, painful, or heavy periods, not realising that these are not normal because of societal conditioning and lack of menstrual education. As a society, we have to do better at educating everyone around menstruation from a young age and doing so in an inclusive way. We also talk about the importance of tracking your cycle in Living PCOS Free and bust myths around issues such as seed cycling for hormonal health.

Since announcing you were releasing this upcoming book, what has been the reaction from you friends, family, clients and followers?

The reaction has been wonderful. We have been incredibly touched by the support we have received from our followers on social media, by our close friends and family and by many people we admire and look up to in the medical, lifestyle medicine and plant-based communities. Most of all, we have been honoured to receive a few especially moving messages from those who have PCOS themselves and who are especially excited about the release. We are definitely a little nervous about the reaction as we inch closer to the publication date but we are so proud of what we have created. We really hope Living PCOS Free will help many people and stand the test of time.

Could you share with us, a PCOS friendly recipe – (either from the book or one you like to make yourself!)

We have over 30 plant-based recipes from our family kitchen in Living PCOS Free which are incorporated into our 21-day plan.

One of our favourite quick and easy recipes in the book is our Paprika Hummus. Eating legumes (beans, lentils, tofu, tempeh, peas) every day is great for short-term and long-term hormonal health as these foods are full of fibre, protein, minerals and vitamins. Hummus is such a versatile dip and this homemade version takes minutes to prepare. It can be enjoyed with a baked sweet potato or potato, on a salad or as a dip with raw vegetables. The recipe also uses aquafaba, the viscous water in which legumes such as chickpeas have been cooked. Aquafaba can be used as an egg replacer as it mimics egg whites in cooking, for example in meringues and marshmallows.

Recipe: Paprika Hummus by Rohini Bajekal and Dr Nitu Bajekal

Serves 4
INGREDIENTS:

1 can of chickpeas, drained and rinsed but set the aquafaba aside
1 can of cannellini beans, drained and discard aquafaba
4 cloves of raw garlic
1/2 tsp of black pepper
1/2 tsp of salt
1/2 tsp of cumin powder
Juice of 2 lemons
2 tbsp of tahini
1/2 tsp of paprika
1-2 tbsp of premium quality cold-pressed extra virgin olive oil (optional)

A sprig of fresh herbs such as parsley (optional)

METHOD:

  1. Drain water from cannellini beans and rinse.
  2. Save the water from the chickpea BPA free can (aquafaba) and use as much of it as you need to blend to a smooth consistency with all the other ingredients in a good quality blender.
  3. Use most of the aquafaba water if you prefer a runnier hummus. Add as you go along to reach desired consistency. Taste and adjust seasoning as preferred and garnish with a few herbs such as fresh parsley if you like and a sprinkle of paprika for colour. Refrigerate and enjoy within 3-4 days.

If you make this recipe, tag us @rohinibajekal and @drnitubajekal and use the hashtag #LivingPCOSFree

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Raising awareness of Polycystic Ovarian Syndrome (PCOS) for PCOS Awareness Month

Blog post written by Rohini Bajekal, co-author of upcoming release ‘Living PCOS Free’, launching in February 2022.

This September is PCOS Awareness Month. Despite PCOS being the most common endocrine condition to affect women of reproductive age and those AFAB (assigned female at birth), with at least 1 in 10 affected, most people have never heard of it. Depending on how hard one looks for the condition, up to 3 in 4 of those with PCOS remain undiagnosed.

PCOS is the number one cause of anovulatory infertility and those with the condition are at greater risk of a number of long-term conditions, including type 2 diabetes, gestational diabetes, cardiovascular disease, metabolic syndrome and endometrial cancer.

PCOS is a chronic condition so, while there is no “cure”, making positive lifestyle changes can go a long way in managing PCOS and its symptoms, including insulin resistance, both in the short-term and longer term. Lifestyle modifications can tackle the underlying insulin resistance. All national and international guidelines recommend lifestyle and behavioural changes as the first line of management for PCOS, even before medications.

Knowledge is power and education is key. Raising awareness of what to look out for allows those with PCOS to access early help, support and advice. This may be through campaigns such as PCOS awareness month, workshops and education in schools or even by opening up the conversation between friends, family and colleagues.

Living PCOS Free is a practical guide which shows readers how to manage PCOS using proven lifestyle approaches alongside conventional medicine. Dr Nitu Bajekal, AKA ‘The Plant Based Gynae,’ dispels misinformation and tackles irregular periods, infertility, acne, weight gain and more.

For the diagnosis of Polycystic Ovarian Syndrome, any two out of three of the criteria below have to be met (Rotterdam criteria, 2003).

  • Ovulatory dysfunction (oligo- or anovulation: not producing eggs on a regular basis)
  • Clinical symptoms or biochemical (lab) evidence of androgen excess: (Increased levels of androgens including testosterone)
  • Polycystic ovarian appearance in one or both ovaries on pelvic ultrasound scan (specific features such as number of follicles, volume of ovary)

There are some common symptoms of PCOS, but it is important to mention that not everyone with the condition will have all the symptoms and vice versa (these symptoms may have other causes) so it is important to get a proper diagnosis:

  • Infrequent periods or missed periods are the most common sign of PCOS (oligomenorrhoea/amenorrhoea). NB: Pain is not a feature of PCOS. Painful and/or heavy periods or painful sex may be signs of endometriosis, fibroids and/or adenomyosis, all of which can affect fertility. Missed or infrequent periods could be a result of other conditions such as hypothalamic amenorrhoea resulting from calorie restriction (disordered eating, for example, or over-exercising).
  • Excess facial/body hair (hirsutism)
  • Acne (often adult and/or cystic)
  • Scalp hair loss (alopecia)
  • Unwanted weight gain
  • Insulin resistance
  • Fertility problems

There are several less well-known symptoms including:

  • Eating disorders, especially binge eating disorders without purging, unlike bulimia. (This may be missed, especially in those from different ethnic groups or those with excess weight. Referral to a therapist, dietitian specialising in medical nutrition therapy or another specialist, such as an endocrinologist or dermatologist, may be needed.)
  • Excessive daytime sleepiness
  • Breathing problems (sleep apnoea, snoring)
  • Acanthosis nigricans (darkened skin: behind the neck, underarms, groin).
  • Psychological issues such as depression and anxiety, which must be addressed.

 

Lifestyle matters and nutrition is the cornerstone

A plant-predominant dietary pattern

Given the commonality of PCOS among those with type 2 diabetes, and the higher risk of other serious health conditions, people with PCOS should be advised to focus on predominantly whole plant foods, including whole grains, beans, fruit, vegetables, nuts and seeds, herbs and spices. These foods are full of fibre and micronutrients that are nourishing and absorbed slowly, helping to normalise blood sugars. We know this works very well in people with type 2 diabetes and metabolic syndrome. Living PCOS Free is packed with tasty and nutritious plant-based recipes with gluten-free and oil-free options.

Exercise

Regular movement in a form that you enjoy is key. Aerobic exercise and resistance training, including high intensity interval training (HIIT) are all recommended to help improve insulin sensitivity in women with PCOS. Aim for 300 minutes of exercise per week (approximately one hour a day) and try to exercise outdoors in natural light.

Sleep

Ensure a regular sleep routine with seven to nine hours of restorative sleep.

Stress management and reduction

Consider exercise, meditation, mindfulness, community work, psychotherapy or yoga to help manage stress and lower cortisol levels which make insulin resistance worse.

Positive social connections

Build or join a community, whether online or offline; ensure you have a support network or a friend you can trust and confide in. Loneliness is a source of chronic stress and is associated with an increased risk of heart disease, high blood pressure and type 2 diabetes.

Avoid or limit risky substances

Eliminate risky substances such as drugs and tobacco and limit alcohol (people with PCOS are at higher risk of non-alcoholic fatty liver disease), which has no health benefits.

Living PCOS Free features an easy-to-follow 21-day plan by Nutritionist Rohini Bajekal, illuminating case histories and plant-based recipes.

https://nitubajekal.com/pcos/

https://nitubajekal.com/pcos-nutrition/

 

Dr Nitu Bajekal MD FRCOG Dip IBLM

Consultant Obstetrician and Gynaecologist

Lifestyle Medicine Physician

 

Rohini Bajekal Nutritionist and Lifestyle Medicine Professional

 

About the authors

Dr Nitu Bajekal, MD is a Senior NHS Consultant Obstetrician and Gynaecologist in the UK with over 35 years of clinical experience in women’s health. Her special interests include Lifestyle Medicine, PCOS, endometriosis, period problems, menopause, precancer, complex vulval problems and medical education. She is a keyhole surgeon with experience in laparoscopic procedures, including robotics.

Rohini Bajekal MA Oxon, MSc Nutrition, Dip IBLM, is a Nutritionist and Board-Certified Lifestyle Medicine Professional based in London. Rohini is passionate about PCOS and has personal experience of living with this condition.