If you are of childbearing age and living in the UAE, then it’s highly probable that a majority of your female friends, colleagues and acquaintances have PCOS. Brought up in conversations over coffee and in water cooler chit-chat, many an adult female expat can be heard speculating about this seemingly Dubai-based phenomenon. And many an unfounded rumour can be heard bouncing back and forth about why this hormone-affecting disease – which leads to weight gain, acne, hair in unwanted places and ultimately infertility – is so prevalent in the UAE. Not only that, but why so many women who move here apparently develop it within their first year.
Dubai expat Claire Wills, a 36-year-old from the UK, says that when she was diagnosed with PCOS, she was given various explanations for her new health issue. “I was fed all sorts of information, not only by my friends but even by my gynaecologist. She told me when I was diagnosed in 2010 that many women who move here develop PCOS within months. She just put it down to a ‘Dubai curse’ and advised me to maintain my weight.”
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The Dubai lifestyle link
In 2010, when Claire was diagnosed, medical professionals were still coming to grips with fully understanding PCOS, despite its initial discovery back in 1935 by Doctors Stein and Leventhal. In the past it was considered a disease brought on by defective ovaries. However, in the past few years, experts are beginning to find common ground regarding the reasons and effective treatments for the world’s leading cause of infertility.
Here in the UAE, a study carried out by Conceive, a gynaecology and fertility hospital in Sharjah, has made the interesting link between PCOS, weight and lifestyle-related diabetes. Dr Pankaj Shrivastav, director of Conceive, says, “It is a well-established fact that we have a much higher percentage of PCOS in the UAE. As a doctor you often hear from expats that they were fine until they ‘came to Dubai’. They had regular cycles, they didn’t have acne and so they blame it on the emirate and the water – but it is not that. It’s because they moved here and gained 10 kilos.”
Dr Shrivastav studied 500 women of different nationalities living in the UAE. He found 42 per cent of those of South Asian descent, 39 per cent of those of Gulf Arab origin and 23 per cent of those with Caucasian ancestry had PCOS, a disease that sees an over production of follicles on the ovary, which, in turn, affects a woman’s hormone levels, periods, ovulation and ultimately chances of conception. He says, “The reason for the figures amongst those ethnicities is because we now know PCOS is very closely connected to diabetes, and both the Gulf and South Asia suffer from diabetes of almost epidemic proportions. The fact is, if a girl has diabetes in the family she has a pretty high chance of developing PCOS.”
The diabetes link
According to Dr Shrivastav’s study of women patients suffering from infertility, 97 per cent from the South Asian group and 81 per cent from the Gulf Arab were suffering from insulin resistance, a leading cause of diabetes. “PCOS is a misnomer,” explains Dr Shrivastav. “It is not the ovaries at fault, but rather a metabolic disorder. What we are seeing is a consequence in the ovaries of a disease that has originated very far away. This disease is called insulin resistance and girls who present with PCOS have a basic problem with their insulin receptors.”
The science denotes that the insulin receptors, which are present on every cell of the body, have the job of bonding the insulin hormone to facilitate the entry of sugar into the body’s cells so it can get nutrition. If, however, there is a defect in the receptor, the insulin comes and sticks to the receptor but can’t get it to work, so the cell can’t access the sugar.
The cells then think they aren’t receiving enough sugar, so send a message asking if the body is making enough insulin. The body responds by making more insulin, leading the pancreas (where the insulin is made) to work overtime – and this is what causes issues for the ovaries, Dr Shrivastav explains. “With these heightened levels of insulin, the receptor starts working and the sugar gets into the cell, so the sugar in the blood is normal – but the consequence of this process is that the body is functioning on high levels of insulin, and it is this that causes problems for the ovaries.”
“It goes to the ovaries and stimulates some cells around the egg and gets them to make a slight excess of male hormone – that is why you quite commonly see girls with PCOS suffering from acne, hair on their face and body, and like men, they start to lose hair from the scalp. That male hormone starts to disrupt the maturation of the egg; it stops growing in a cyclical way and because of that process, the sufferer stops having normal periods.” A spectrum disease It is not all doom and gloom for women living in the UAE, however. According to Dr Michael Fakih, the founder and director of Fakih IVF – an infertility, gynaecology, obstetrics, genetics and IVF centre that he set up in 2011 – PCOS is a spectrum disease and there’s no one-size-fits-all approach. He highlights that there is a clear distinction between PCOS and PCOS disease, and that the two can be differentiated by grades. Those who are only grade 1-2 on the spectrum will present few symptoms other than cystic ovaries, which are unlikely to affect fertility unless other lifestyle factors mean it is allowed to manifest into the PCOS disease. A woman who has developed the disease, he explains (approximately grade 5-7) will demonstrate symptoms such as acne, obesity, irregular cycles and unwanted hair.
“If the ovary has multiple cysts it doesn’t have to mean you have the disease,” says Dr Fakih. “There is a tendency in the UAE not to make this distinction and therefore to over-diagnose PCOS. The major signs of the disease are either obesity or a lack of ovulation. Here in the UAE, many PCOS diagnoses are for women who just have more than 10 follicles or cysts on each ovary, but they are not obese and have normal ovulation. Extending the diagnosis to encompass these women means the instance of PCOS will be very high, but if you just look at the actual disease it is far lower. In the US 5 per cent of women have the PCOS Disease, in Europe it’s 5 or 6 per cent and here in the UAE its about 7 per cent.”
Dr Farhana Bin Lootah, specialist in internal medicine at the Imperial College London in Abu Dhabi, agrees. “I could do ultrasounds on 100 women and find cystic ovaries in maybe 40 of them, but they wouldn’t have PCOS [disease]. That would mean that they have regular periods, they wouldn’t have androgen [male hormone] excess and they wouldn’t have insulin resistance.”
He adds, “When you start having abnormal ovulation, are on the obese side and have insulin resistance and high male hormone levels then the PCOS has become more severe. That’s when it becomes difficult and women can develop diabetes, hypertension, infertility and obesity.”
Finding a cure
The good news is that PCOS can be reversible if a few dietary guidelines are followed. In the past experts did not associate PCOS and its development with weight, however today doctors are in agreement that maintaining a healthy BMI is key to managing, and ultimately reversing, PCOS.
Recent research into the nutritional approach to PCOS has shown that as women with PCOS lose weight, their hormone levels gradually return to normal. Testosterone levels fall, serum insulin levels descend and symptoms of PCOS reduce. Treatment has therefore begun to focus on diet, not only because it improves the condition in patients with full-blown PCOS disease, but because women with the diagnosis who stay slim and are still ovulating are highly unlikely to ascend the gradient PCOS ladder towards disease. Dr Farhana says, “Extra pounds exacerbate the PCOS condition, so even if a woman who’s been diagnosed with PCOS has a normal BMI, it’s likely she could still benefit from losing a few kilos.”
Dr Fakih adds,“Lifestyle changes are absolutely key. If someone has cysts, they should reduce their sugar intake and maintain their weight.” He says that the lifestyle changes you need to make will depend on the severity of thePCOS. “Those girls who have PCOS between grades 1 or 2 need to make minimal lifestyle changes to be OK. Those with grade 3 or 4 need to practise preventative techniques and they will reverse back to stage 1 or 2. However, if they don’t, they are likely to get worse and fall into grades 6 or 7.”
For women with PCOS who make positive lifestyle changes to manage it, all the doctors agree that the fertility outlook is bright. As Dr Shrivastav says, “If a woman already has the condition, as long as she remains healthy, is careful about what she eats and remains slim, the disease will not manifest. The odds are she will have a normal cycle and will get pregnant normally.”
BEATING THE ODDS
Dubai expat Clare Lees, 32, who was diagnosed with PCOS in the UAE last year, decided to kick-start a healthy living campaign called #BlogFit. She documented her struggle with PCOS and shared experiences with an online community by filming her weight-loss campaign.
“After my diagnosis I got talking to people in the UAE and I realised that it was a subject that was swept under the carpet. It seemed as though it was a taboo subject and I felt people were too afraid to come out and openly discuss it.
“That’s when I decided to do the video because it’s not just here, it’s the world over that people tackle it on their own and don’t understand it.”
Clare took up what she says was a ‘slow, steady, healthy weight-loss routine’ that involved exercising, becoming selective about which carbohydrates she ate, and cutting out sugary foods. She successfully lost 8kg over four months and today is a glowing mother-to-be due to give birth in January.
“When I had a positive pregnancy test it was the most amazing feeling ever, but to be honest, I am a very positive person and I had looked into positive stories instead of resigning myself to not having a baby. We did know that women with PCOS have a higher risk of miscarriage and that was a very scary possibility for us, but I just really focused on having a good attitude and learning as much as I could about what I had and what I could do to improve it.”
Cystic ovaries vs PCOs disease
Polycystic Ovary Syndrome (PCOS) is a complex condition that leads to women developing multiple follicles on their ovaries due to genetics and lifestyle choices. Although the symptoms may begin in the early teens after the first menstrual cycle, the condition affects up to 10 per cent of all women between the ages of 15 and 50 and is particularly common among women with ovulation problems around 75 per cent). PCOS has some genetic basis and it is more likely to develop if there’s a family history of diabetes. Women are also more at risk if they’re overweight. Maintaining weight below a critical threshold is key in determining whether a woman will develop the symptoms of the condition.
Many women diagnosed with PCOS in fact only have cystic ovaries rather than full-blown PCOS disease, or are on the lower scale of the PCOS spectrum. Those with the most extreme form tend to be overweight, prone to acne, have few or no periods and grow more body hair, often on the face and breasts. Those who only present cystic ovaries could be slim and not demonstrate any of the symptoms listed in the pink box on the right.
Symptoms that may suggest you are developing PCOS
• Irregular cycle that manifests itself as either no menstrual period or irregular bleeding
• Weight gain
• Excess hair growth on the face, chest, back, stomach, thumbs, or toes
• Acne and oily skin
• Fertility problems, such as not ovulating or repeat miscarriages
• Insulin resistance, which can cause obesity and skin tags
If you have several of the above symptoms or PCOS in the family, certain investigations can be done to confirm it, including blood tests for hormones and an ultrasound examination. Once the diagnosis is made, nothing more needs to be done for those women who have no other symptoms, for example, if their fertility is not an issue, if their weight is within normal limits and if they do not have excess body hair. If any of the symptoms are an issue, further doctor’s advice and treatment will, of course, be needed.