If you’re dealing with both polycystic ovary syndrome (PCOS) and bacterial vaginosis (BV), you might be wondering if there’s a connection between the two. While PCOS and bacterial vaginosis are separate conditions, it’s not far-fetched to believe that PCOS could be affecting your vaginal health — especially since hormonal changes have been linked to both. 

While PCOS doesn't directly cause bacterial vaginosis, some research suggests that it can create conditions that make it more likely for bacterial vaginosis to develop.

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome is a complex condition that affects approximately 10% of reproductive-aged people assigned female at birth. It influences multiple body systems, but the metabolic, reproductive, and hormonal systems are particularly impacted.

The medical definitions and criteria for PCOS vary, but most diagnostic guidelines agree that women with PCOS must present with at least two of the following three clinical symptoms:

  • High levels of androgens (male sex hormones) 
  • An irregular menstrual cycle and ovulation
  • Polycystic ovaries. 

Polycystic ovary syndrom can have a profound impact on the physical and psychological well-being of people living with it. Let’s dive in and learn more about PCOS and how it can affect health and of course, the vaginal microbiome. 

Symptoms of polycystic ovary syndrome

In addition to the three key clinical signs we discussed above, women with polycystic ovary syndrome often experience a variety of other symptoms as well. Common symptoms of PCOS include:

  • Weight gain and a higher body mass index (BMI)
  • Excess facial and body hair, including the chest, stomach, and back (hirsutism)
  • High blood sugar (diabetes or pre-diabetes)
  • Fertility and pregnancy problems
  • Sleep apnea
  • Mood disorders like depression and anxiety. 

Polycystic ovary syndrome also increases one’s risk of developing other medical conditions like metabolic syndrome, cancer of the uterine lining (aka endometrial cancer), and heart disease, particularly after menopause.

Although polycystic ovary syndrome can be present from a young age, many of these common symptoms, like obesity and decreased fertility, don’t become obvious until one is in their twenties or thirties. For this reason, polycystic ovary syndrome often isn’t diagnosed until a person exhibits other conditions like these.

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What causes polycystic ovary syndrome?

While many hypotheses exist, no single explanation has emerged as an undisputed answer to the question: what causes polycystic ovary syndrome? Gender health gap, we meet again!

Most current research agrees that hormonal imbalances likely play an important role in its development. The ovaries of women with PCOS typically produce excessive levels of androgen hormones (testosterone and its precursors). 

Additionally, women with PCOS often display irregularities in their insulin hormone signaling systems, which can impair the body’s ability to process the sugars from food. However, researchers still don’t fully understand what triggers the development of these hormonal imbalances. Here are a few current hypotheses:

  • Environmental pollutants may contribute to the development of PCOS. Contaminants and chemicals in drinking water and certain food products may disrupt the endocrine system, leading to hormonal changes. 
  • Environmental factors may interact with certain genes and lead to PCOS development. Some environmental chemicals appear to change how genes are “activated” (or not activated), which can lead to disease development. These changes in gene activation may even be carried through to the next generation.

Despite this abundance of hypotheses, no single theory adequately accounts for all aspects of PCOS and its development.

How is polycystic ovary syndrome diagnosed?

There is no single, simple test for polycystic ovary syndrome. Several diagnostic guidelines for clinicians exist, each with similar, but not identical, criteria.

As we mentioned earlier, a person must have at least two of the three key clinical symptoms — polycystic ovaries, an irregular menstrual cycle, and high androgen levels — to be diagnosed with PCOS. 

The presence of just one of these findings neither guarantees nor rules out a PCOS diagnosis. The term “polycystic” in the name implies that a person must have many cysts on their ovaries to be diagnosed with PCOS, but this isn’t always the case. Some women with PCOS won’t have ovarian cysts that appear on ultrasound images. 

Current research cautions against diagnosing PCOS based solely on ultrasound imaging of the ovaries. There is some disagreement about how many cysts are “too many” and what size the cysts must be to be considered problematic. 

Given these discrepancies, it’s perhaps unsurprising that it takes an average of two years and consultations with three different healthcare providers to receive a PCOS diagnosis. Understandably, this slow diagnostic process often causes patients to become frustrated and dissatisfied with their care.

How is polycystic ovary syndrome treated?

We don’t understand what causes polycystic ovary syndrome, so unsurprisingly, we don’t yet have a cure for it. Currently, treatment focuses on managing each individual’s unique symptoms. Multiple treatment approaches are often required to target the various symptoms that PCOS can cause — these include:

Managing fertility issues related to PCOS is a field unto itself. Fertility specialists have developed complex treatment protocols specifically for women with PCOS. Many women with PCOS first receive the diagnosis when working with a fertility specialist to become pregnant. Fortunately, researchers are continually working to develop more effective, safe ways to help women with PCOS conceive if they so choose.

A note on fatphobia in medicine and PCOS

It’s very common for women with PCOS to have increased body weight. From a strict medical perspective, this can be monitored in case it could be contributing to other health problems. However, increased body weight very often presents a barrier to appropriate care. 

Too many women with PCOS report negative medical experiences related to their weight. Many are simply told to “lose weight” without receiving the tools to do so in a safe and effective manner. Fat shaming is a well-documented phenomenon in healthcare, and it often leads to delays in the diagnosis and management of PCOS. 

Interestingly, a 2007 review reported that while up to 80% of Americans with PCOS are overweight or obese, this rate is much lower outside of the United States (as low as 20% in some places). This suggests that increased body weight isn’t always a direct result of PCOS, but may be at least partly related to lifestyle factors specific to the U.S. 

If you live with increased body weight and suspect you could have PCOS, don’t be afraid to self-advocate to ensure that your concerns are being heard — this is an unfortunate but necessary reality of existing under the modern American medical system. 

Many advocates within the fat acceptance community have pioneered strategies for reducing weight stigma in medicine. We still have a long way to go, but PCOS and body positivity influencers are paving the way every day. 

What is bacterial vaginosis? 

Bacterial vaginosis is the most common vaginal infection in women of reproductive age. It occurs when there’s an overgrowth of anaerobic bacteria in the vagina, which disrupts the balance of vaginal bacteria — especially Lactobacilli, which normally keep the vaginal environment acidic and protects against infections. Symptoms of bacterial vaginosis include: 

  • A thin, grayish vaginal discharge
  • A strong fishy odor
  • Vaginal itching and discomfort.

How does PCOS impact the vaginal microbiome?

Research has found a link between polycystic ovary syndrom and both the gut and vaginal microbiome.

PCOS and the gut microbiome

The gut microbiome (aka the GI system) is highly diverse, made up of 300-500 different microbial species on average. It influences digestion, the immune system, and a host of other important bodily functions. 

Research has established that the gut microbiome can impact the development of obesity and diabetes. Additionally, the gut microbiome and circulating hormones in the bloodstream can affect each other in both directions. Given these connections, it’s perhaps unsurprising that recent research is finding connections between the gut microbiome and the development and course of polycystic ovary syndrome.

The research on the gut microbiome and PCOS is growing fast. A recent review systematically analyzed the results of twelve different studies examining the gut microbiome in women with PCOS.

The results of these studies generally agreed that the gut microbiome of women with PCOS are more diverse than those without PCOS. They noted that, relative to women without PCOS, the gut microbiome of those with the condition had increased levels of disruptive bacteria (Prevotella, Bacteroides, and Escherichia) and decreased levels of beneficial bacteria: Lactobacillus and Bifidobacteria. 

PCOS and the vaginal microbiome

Remember how we’ve been geeking out over the growing body of evidence showing the connection between the gut and vaginal microbiome (aka the gut-vagina axis)? It’s also likely that PCOS-related disruptions of the gut microbiome could also impact the vaginal microbiome. Unfortunately, research on PCOS and the vaginal microbiome is still quite sparse. 

Additionally, the majority of published work in this area originates in China, a predominantly homogenous population, which limits our ability to generalize the research findings to racially diverse groups of people. Here’s what we know right now:

  • Women with PCOS have a higher vaginal microbiome diversity and lower levels of protective vaginal bacteria (like Lactobacilli species) than those of women without PCOS. 
  • The research is in conflict regarding the other vaginal bacteria potentially affected by PCOS. 
  • Some evidence suggests that Mycoplasma species are elevated in the vaginal microbiome of women with PCOS. These data even suggest that Mycoplasma could potentially serve as a biomarker when designing new tests to screen for PCOS, however more research is needed to confirm this finding. 

Can PCOS cause BV? 

The causes of both PCOS and bacterial vaginosis are still unknown, and at the moment, the research on the vaginal microbiome in PCOS is simply too sparse for us to draw definitive conclusions about the role of specific bacteria in the vaginal health of women with PCOS. 

In PCOS, elevated levels of male sex hormones and lower levels of estrogen could disrupt the vaginal microbiome. Estrogen helps maintain a healthy environment in the vagina by promoting the growth of Lactobacillus bacteria, which keep the vaginal pH acidic and inhospitable to harmful bacteria. When estrogen levels drop, as they often do with PCOS, this protective balance can be thrown off, making it easier for bacterial vaginosis to take hold.

Though it’s true that some studies have found a link between PCOS, decreased Lactobacilli, and a higher vaginal microbial diversity, as of now it wouldn’t be fair to say that PCOS itself is a direct cause of bacterial vaginosis. 

As always, Evvy will keep pushing for more research to help us better understand the conditions that can impact the health of everyone with a vagina. If you have PCOS and want to take better charge of your health, check out the Evvy Vaginal Health Test and start learning about your vaginal microbiome today.

FAQ

Can a hormone imbalance cause BV?

Yes, a hormone imbalance can increase the risk of developing bacterial vaginosis. Hormones, especially estrogen, play an important role in maintaining a healthy vaginal microbiome. Estrogen helps support the growth of Lactobacillus bacteria, which are beneficial bacteria that keep the vaginal pH acidic. This acidic environment makes it harder for harmful bacteria to thrive. When estrogen levels drop, such as during menopause, pregnancy, or due to conditions like polycystic ovary syndrome, the vaginal pH can become less acidic. This shift in pH can create a more favorable environment for harmful bacteria to overgrow in the vaginal microbiome, leading to bacterial vaginosis.

Why am I suddenly getting BV all the time?

If you're suddenly experiencing frequent bacterial vaginosis, there could be several underlying reasons. One common factor is changes in your vaginal microbiome, which can be influenced by hormonal fluctuations, stress, or lifestyle changes. For instance, hormonal shifts during your cycle, pregnancy, or menopause can disrupt the balance of vaginal bacteria, making it easier for harmful bacteria to overgrow. Another possible reason is recent antibiotic use, which can kill both harmful and beneficial bacteria, upsetting the natural balance of your vaginal flora. Douching and over-using feminine hygiene products can also create an environment where bad bacteria thrive. Sex might also play a role, as introducing new bacteria during sexual intercourse can lead to an imbalance. If your immune system is weakened by stress, illness, or other health issues, it may struggle to maintain a healthy bacterial balance, making you more susceptible to bacterial vaginosis. If bacterial vaginosis keeps coming back, it’s important to consult with a healthcare provider.

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