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Polycystic Ovarian Syndrome

Polysystic ovary syndrome (PCOS) is a medical condition that causes irregular menstrual periods because monthly ovulation is not occurring and levels of androgens (male hormones) in women are elevated.  The condition occurs in about 5 to 10 percent of women.  The elevated androgen levels can sometimes cause excessive facial hair growth, acne and/or male-pattern hair thinning.  Most, but not all, women with PCOS are overweight or obese.  Additionally, they are at higher than average risk of developing diabetes and obstructive sleep apnea.  For women with PCOS who want to become pregnant, fertility pills or injections are often needed to help women ovulate.

Although PCOS is not completely reversible, there are a number of treatments that can reduce or minimize bothersome symptoms.  Most women with PCOS are able to lead a normal life without significant complications. 

Cause

The cause of polycystic ovary syndrome (PCOS) is not completely understood.  It is believed that abnormal levels of the pituitary hormone luteinizing hormone (LH) and high levels of male hormones (androgens) interfere with normal function of the ovaries.

In women with PCOS, multiple small follicles (small cysts) may develop in the ovary.  Therefore, small follicles (4 to 9 mm in diameter) accumulate in the ovary, hence the term polycystic ovaries.  None of these small follicles are capable of growing to a size that would trigger ovulation.  As a result, the levels of estrogen, progesterone, LH and FSH become imbalanced.

Androgens are normally produced by the ovaries and the adrenal glands.  In addition, some tissues (such as fat cells and the lever) can convert other steroid hormones into androgens.  Examples of androgens include testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEA-S).  Androgens may become increased in women with PCOA because of the high levels of LH, but also because of high levels of insulin that are usually seen with PCOS.

Symptoms

The classic symptoms of polycystic ovary syndrome (PCOS), include absent or irregular and infrequent menstrual periods, increased body hair growth or scalp hair loss, acne and difficulty becoming pregnant.
Signs and symptoms of PCOS usually begin around the time of puberty, although some women do not develop symptoms until late adolescence or even into early adulthood.  Because hormonal changes vary from one woman to another, patients with PCOS may have mild to severe acne, facial hair growth or scalp hair loss.

Menstrual irregularity

If ovulation does not occur, the lining of the uterus (called the endometrium) does not uniformly shed and re-grow as in a normal menstrual cycle.  Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding.  Irregular or absent menstrual periods can increase a woman’s risk of endometrial overgrowth (called endometrial hyperplasia) or even endometrial cancer.
Women with PCOS usually have less than six to eight menstrual periods per year.  Some women have normal cycles during puberty, which may become irregular if the woman becomes overweight.

Weight gain and obesity

PCOS is associated with gradual weight gain and obesity in about one-half of women.  For some women with PCOS, obesity develops at the time of puberty.

Hair growth and acne

Male-pattern hair growth (hirsutism) may be seen on the upper lip, chin, neck, sideburn area, chest, upper or lower abdomen, upper arm and inner thigh.  Acne is a skin condition that causes oily skin and blockages in hair follicles.

Insulin abnormalities

PCOS is associated with elevated levels of insulin in the blood.  Insulin is a hormone that is produced by specialized cells within the pancreas; insulin regulates blood glucose levels.  When blood glucose levels rise (after eating, for example), these cells produce insulin to help the body use glucose for energy.
Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS.  Among women with PCOS, up to 35 percent of those who are obese develop impaired glucose tolerance (“prediabetes”) by age 40, while up to 10 percent of obese women develop type 2 diabetes.  The risk of these conditions is much higher in women with PCOS compared with women without PCOS.  A family history of diabetes, overweight and obesity, as well as race and ethnicity (particularly African American and Hispanic) can increase the likelihood of developing diabetes among women with PCOS.

Infertility

Many women with PCOS do not ovulate regularly, and it may take these women longer to become pregnant.  An infertility evaluation is often recommended after 6 to 12 months of trying to become pregnant.

Heart disease

Women who are obese and who also have insulin resistance or diabetes might have an increased risk of coronary artery disease, the narrowing of the arteries that supply blood to the heart.  It is not known for sure if women with PCOS are at increased risk for this condition.  Both weight loss and treatment of insulin abnormalities can decrease this risk.

Sleep apnea

Sleep apnea is a condition that causes brief spells where breathing stops during sleep.  Patients with this problem often experience fatigue and daytime sleepiness.  In addition, there is evidence that people with untreated sleep apnea have an increased risk of insulin resistance, obesity, diabetes, cardiovascular problems, such as high blood pressure, heart attack, abnormal heart rhythms, or stroke.  This risk may be changes in heart rate and blood pressure that occur during sleep.

Sleep apnea may occur in up to 50 percent of women with PCOS.  The condition can be diagnosed with a sleep study and several treatments are available.

Diagnosis

There is no single test for diagnosing polycystic ovary syndrome (PCOS).  You may be diagnosed with PCOS based upon your symptoms, blood tests and physical examination.  Expert groups have determined that a woman must have two out of three of the following to be diagnosed with PCOS:

● Irregular menstrual periods caused by anovulation or irregular ovulation
● Evidence of elevated androgen levels.  The evidence can be based upon signs (excess hair growth, acne or male-pattern balding) or blood tests (high androgen levels)
● Polycystic ovaries on pelvic ultrasound

In addition, there must be no other cause of elevated androgen levels or irregular periods.

Blood tests are usually recommended to determine whether another condition is the cause of your signs and/or symptoms.  Blood tests for pregnancy, prolactin level, thyroid-stimulating hormone (TSH) and follicle-stimulating hormone (FSH) may be recommended.  Insulin levels are not used to diagnose PCOS partly because insulin levels are high in people who are above normal body weight and because there is no level of insulin that is “diagnostic” for PCOS.

If PCOS is confirmed, blood glucose and cholesterol testing are usually performed.  An oral glucose tolerance test is the best way to diagnose prediabetes and/or diabetes.  A fasting glucose level is often normal even when prediabetes or diabetes is present.  Many clinicians who treat PCOS patients also recommend screening for sleep apnea with questionnaires or overnight sleep studies in a sleep laboratory.  In women with moderate to severe hirsutism (excess hair growth) blood tests for testosterone and dehydroepiandrosterone sulfate (DHEA-S) may be recommended.

All women who are diagnosed with PCOS should be monitored by a healthcare provider over time.  Symptoms of PCOS may seem minor and annoying and treatment may seem unnecessary.  However, untreated PCOS can increase a woman’s risk of other health problems over time.

Treatment Options

Oral contraceptives

Oral contraceptives are the most commonly used treatment for regulating menstrual periods in women with PCOS.  OCs protect the woman from endometrial (uterine) cancer or overgrowth by inducing a monthly menstrual period.  OCs are also effective for treating hirsutism and acne.

Oral contraceptives decrease the body’s production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens.  These treatments can be used in combination to reduce and slow hair growth.  Oral contraceptives and anti-androgens can also reduce acne.

Progestin

Another method to treat menstrual irregularity is to take a hormone called progestin for 10 to 14 days every one to three months.  This will induce a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not prevent pregnancy.  It does reduce the risk of uterine cancer.

Hair treatments

Excess hair growth on the face and/or other parts of the body can be removed by shaving or use of electrolysis, or laser therapy.  In women with PCOS, hormonal treatment of excess hair growth is typically approached in a two step process.  The first step is to prescribe an estrogen-progestin contraceptive (ie, a birth control pill).  If after six months of hormone treatment sufficient improvement in excess hair growth has not been achieved, a second medication called spironolactone, an antiandrogen, is added.  If hormone treatment with an estrogen-progestin results in a satisfactory reduction in excess hair growth, this therapy is continued.

Weight loss

Weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods and other symptoms of PCOS.  For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular.  Weight loss can often be achieved with a program of diet and exercise.

Metformin

Metformin (Glucophage) is medication that improves the effectiveness of insulin produced by the body.  It was developed as a treatment for type 2 diabetes but may be recommended for women with PCOS in selected situations.

Treatment of infertility

If tests determine that lack of ovulation is the cause of infertility, several treatment options are available.  These treatments work best in women who are not obese.

The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss.  Even a modest amount of weight loss may allow the woman to begin ovulating normally.  In addition, weight loss can improve the effectiveness of other infertility treatments.

Clomiphene is an oral medication that stimulates the ovaries to release one or more eggs.  It triggers ovulation in about 80 percent of women with PCOS and about 50 percent of these women will become pregnant.

If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy (FSH injections) may be recommended.  Ovulation occurs in almost all women with PCOS who use gonadotropin therapy; approximately 60 percent of these women become pregnant.

More information is available at the following sites:

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001408/
http://www.medicinenet.com/polycystic_ovary/article.htm

 

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