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Polycystic Ovary Syndrome

Overview

An estimated 15% of women of reproductive age in the United Kingdom suffer with the effects of Polycystic Ovary Syndrome. It is the most common hormonal disorder among women and is a leading cause of infertility. Even worse, the disorder often goes undiagnosed because of its many baffling and seemingly unrelated symptoms.

The condition is defined by the presence of hormonal problems, excess hair growth and/or acne, irregular menstrual cycles and polycystic ovaries, although not all patients have all these features. The term 'polycystic' means 'many cysts' and PCOS gets its name because of the clusters of small, pearl-size cysts in the ovaries. These cysts are fluid-filled bubbles (called follicles) that contain eggs that have not yet been released during ovulation because of the hormonal imbalance.

While the ovaries and adrenal glands of all women release small amounts of 'male hormones,' called androgens, women with PCOS produce levels of these types of hormones in slightly higher amounts. Androgens play a role in helping women grow and develop strong bones and muscles strength, and in sexual function. However, higher levels of these hormones lead to hormone imbalances that can interfere with ovulation and normal egg development. Instead of maturing and being released as usual, each month, the cysts containing the eggs build up in the ovaries. This results in irregular or infrequent ovulation and, in most women, irregular and infrequent menstruation.

The build-up of egg-containing cysts within the ovary then leads to the 'polycystic' appearance of the ovaries, and to their frequent enlargement in size, in PCOS. However, it is important to note that there is a distinction between the large cysts (generally bigger than 2 cm) sometimes seen in women and which may need more careful medical attention, and the small cysts seen in women with polycystic ovary syndrome. It should also be noted that it is normal for all women who are of child-bearing age to have a few small cysts in their ovaries, since these hold the eggs that will ovulate in the next few cycles.
PCOS affects several body systems, putting women at increased risk for problems such as diabetes, heart disease, and certain kinds of cancer. The first signs of the disorder often present themselves at puberty with irregular or absent menstrual cycles. Other obvious signs include acne, abnormal facial and bodily hair growth, and thinning of hair on the scalp. While thin women can have polycystic ovary syndrome, weight gain is more likely. Some women with PCOS also suffer from depression, most likely because of their symptoms. Because women with PCOS ovulate (release an egg monthly) infrequently, they often have difficulty getting pregnant when desired and are often diagnosed when they cannot conceive.

While PCOS was identified almost 80 years ago by Drs. Stein and Leventhal, and is sometimes called the Stein-Leventhal Syndrome, the cause remains unknown. Research suggests that many women with this condition may have decreased sensitivity to insulin, called 'insulin resistance.' Insulin, a hormone produced by the pancreas, is necessary to carry sugar from the bloodstream into the cells, where it is converted into energy. When cells are resistant to insulin, it means that the effect of insulin on sugar, and other functions, is deficient. More insulin than normal is required to be produced by the pancreas to ensure that the body cells absorb enough sugar. This leads to high insulin levels in the blood stream which, among other effects, make the ovaries overproduce male hormones, leading to a hormone imbalance that triggers or worsens some of the symptoms of PCOS. The high insulin levels may also cause areas of the skin (for example on the neck) to darken or develop skin tags. Eventually, the pancreas may not be able to maintain the high insulin levels necessary to keep sugar levels normal and the patient develops diabetes.

Finally, PCOS seems to run in families, and it is likely that it is a genetic disorder. Sisters of polycystic ovary syndrome patients have about a 50% chance of also having PCOS.

If you suspect you have PCOS you should see a doctor who is experienced in PCOS. Unfortunately there is no simple test for this condition and a definitive diagnosis requires a careful and thorough evaluation. A doctor will take your medical history, perform a physical exam, and check all your androgen hormone and glucose levels. She or he may also arrange for an ultrasound to look at your ovaries. Other disorders such as those that affect the adrenal or thyroid glands may mimic PCOS. For this reason, a careful evaluation of your individual case history and laboratory tests are essential for an accurate diagnosis. An endocrine specialist familiar with this syndrome is best qualified for diagnosis and treatment of PCOS.
While there is still no cure for PCOS, the good news is that there are many effective ways to treat polycystic ovary syndrome. Together with changes in diet and exercise, these treatments are empowering women with PCOS to lead healthier and more satisfying lives. Even the problem of infertility can often be corrected and conception can occur.

Polycystic Ovary Syndrome Symptoms

Because of the hormone imbalance caused by PCOS, a variety of obvious symptoms can occur. Remember, though, that PCOS is a syndrome, meaning that it is a collection of signs (physical findings) and symptoms (patient complaints), so each person may have a different combination of features than another person. If you have two or more of the following symptoms, you should see your doctor for an accurate diagnosis and a treatment for PCOS that is right for you.

Irregular or absent menstrual periods. Nine or fewer menstrual cycles per year may be a clue that a woman may have PCOS. Bleeding may be heavier than normal.
Infertility. Women with polycystic ovary syndrome do not form eggs regularly so they may be unable to conceive.
Excess or unwanted body or facial hair growth. PCOS may cause usually fine hairs on a woman's face to become heavier and darker. There may also be increased hair growth on a woman's arms, legs, and elsewhere on her body.
Thinning hair on the scalp may be present.
Weight problems. Many women with polycystic ovary syndrome gain weight easily and have difficulty losing extra pounds. Weight gain often is concentrated around the waist. Weight gain is of concern because it puts women at risk for the metabolic problems such as type II diabetes and heart disease.
Skin problems

Acne is sometimes found on the face, chest, and back.
Skin tags, about the size of small raisins, are sometimes found in the armpits or neck.
Darkening and thickening of the skin may occur around the neck, groin, underarms, or skin folds. This condition is called 'acanthosis nigricans' and often a result of decreased sensitivity to insulin.

In addition to irregular periods and some of the symptoms described above, women with PCOS are at higher risk for a number of serious health conditions. These conditions may go unnoticed, but are potentially dangerous, and include the following:

Diabetes, elevated insulin levels, or insulin resistance. Many women with PCOS have problems using their body's insulin, the hormone that carries sugar from the blood stream into our cells. About 30 percent of women with polycystic ovary syndrome will have some problem with processing blood sugar. This is a major risk factor for adult-onset diabetes, a disease characterized by too much sugar in the bloodstream.
Heart and blood vessel diseases including high blood pressure - Women with PCOS often have elevated levels of the bad cholesterol (LDL), low levels of the good cholesterol (HDL), and high levels of other fats, including triglycerides. These factors are known to increase the risk of heart attack or stroke later in life.
Cancer of the uterus. The lining of the uterus - called the endometrium - normally builds up and is shed with the menstrual period each month. Because of irregular menstrual cycles and lack of ovulation in women with PCOS, the lining of the uterus may not shed as often as is desirable. In this case, the endometrium may become extremely thick. If polycystic ovary syndrome goes untreated, and the lining of the uterus does not shed as it should, this may increase the risk of cancer over time.
Sleep apnoea. Characterized by brief interruptions of breath during sleep, sleep apnoea is among the most common cause of all sleep disorders, but most people do not know they have it. These breathing irregularities cause snoring and irregular sleep which results in daytime drowsiness, putting people at risk for accidents. Untreated, the problem can be life threatening, putting individuals at increased risk for stroke, heart disease and heart attacks.

The more obvious signs of polycystic ovary syndrome described above are particularly troublesome for women from puberty through their reproductive years. As women approach menopause - the time of life when periods begin to taper off and eventually stop - they may notice that many of their PCOS symptoms diminish in severity. Some women may even begin to experience regular menstrual cycles for the first time. Unfortunately, the risk for diabetes and heart disease increases with age. This means that if you have had symptoms of polycystic ovary syndrome for most of your life, then you should be carefully evaluated for diabetes, insulin resistance, and heart disease, even if your overall symptoms are improving with age.

Polycystic Ovary Syndrome Treatment Options

Once you are correctly diagnosed, you can begin any of a number of treatments for PCOS depending on the specific symptoms you are experiencing, your age, and your plans regarding pregnancy. Some treatments can relieve distinct symptoms such as acne and weight gain, for example. Other treatments can help to put your body back into balance with the proper amounts of hormones. The following options for treatment for PCOS have helped many women:

Birth control pills, or oral contraceptives, contain female hormones that help to regulate menstrual cycles. Certain contraceptives also help to lower levels of androgens, reducing abnormal hair growth and improving acne.
Insulin-sensitizing medications used to treat adult-onset diabetes are useful for many women with PCOS. Metformin is the most commonly used drug, and is frequently used in the treatment of women with PCOS who have difficulty in losing weight.
Ovulation Induction. In some women who wish to become pregnant, inducing ovulation, which is the release of an egg, is necessary. The initial treatment to induce ovulation is usually an oral medication called clomiphene citrate, which is taken for five days. If clomiphene is not effective, the next order of treatment often includes an injection of gonadotropins. Gonadotropins are hormones that the body produces to stimulate ovulation. Other infertility treatments may include additional medications or laparoscopic surgery. High-tech treatments include in-vitro fertilization, in which an egg fertilized with sperm is implanted in the uterus. The insulin sensitizer metformin appears to be helpful in inducing ovulation and conception in some patients, but it is generally less effective than clomiphene or gonadotropins in inducing pregnancy.
Reverse circadian rhythm prednisolone treatment is an old-fashioned but frequently very effective treatment for PCOS associated infertility. It consists of taking a small dose of prednisolone (cortisol like medicine) on waking and another dose at night-time, with the objective being to reduce the body’s own production of androgens. The total dose of prednisolone taken is equivalent to the body’s own production and therefore usually does not cause any of the long –term adverse effects seen with higher dose steroid treatment. However, if these do occur, the dose can be reduced to avoid these effects.
Androgen-blocking (anti-androgen) medications can be used to treat several PCOS symptoms, including excess or unwanted hair growth and, to a limited degree, acne and scalp hair loss. Spironolactone, flutamide, finasteride and cyproterone acetate can help to relieve the symptoms of excessive facial and bodily hair, as well as thinning hair on the scalp and acne. These medications can be taken along with oral contraceptives and indeed the latter are generally encouraged as conceiving while on these anti-androgens can have significant adverse effects on the baby.
Topical anti-hair-growth medications also can help to slow the growth of facial hair in women with PCOS, specifically a lotion containing eflornithine hydrochloride (Vaniqa). The active ingredient in this medication blocks an enzyme found in the hair follicle of the skin needed for hair growth. This results in slower hair growth within a few weeks of treatment.
Other methods of treatment for excess hair caused by PCOS include bleaching, depilatory creams, and shaving excess hair. These treatments are safe and easy approaches. Electrolysis and laser treatments to remove hair also can be effective.
Treatments for hair loss tend not to work for everyone. Some women find improvements with the use of anti-androgen pills. Others find that minoxidil - a topical medication - can help as well.
Proper nutrition, and dietary restriction if overweight, is a critical aspect of treatment for PCOS. Many women with PCOS find success by reducing their total intake of refined carbohydrates (sugars and starches) and fats and replacing them with an increased intake of fruits and vegetables. Your diet should also include enough protein to control the amount of sugar in your blood.
Exercise helps the body use insulin more effectively and is highly recommended as well. It helps with weight loss and keeping off weight. Many scientific studies have shown that exercising for at least 30 minutes a day, about 3-5 days a week, is highly beneficial to your health.
Acne treatments sold over the counter also can help to control the skin blemishes related to polycystic ovary syndrome, although some patients may require additional medications, such as isotretinoin.

Skin problems other than acne may be treated in different ways. You can ask your doctor or dermatologist to remove skin tags using just a simple anaesthetic on your skin. The dark blemishes on your skin may fade if you can reduce your insulin level by weight loss or through the use of insulin-sensitizer medications.

Polycystic Ovary Syndrome Lifestyle and Prevention

If you have been having irregular periods and some of the other symptoms of polycystic ovary syndrome, please see your GP or an endocrinologist. Having infrequent periods is not just a nuisance; it can lead to complications like cancer of the uterus. Early treatment of PCOS can contribute to your long-term health and well being, and improve your quality of life. Polycystic ovary syndrome appears to be an inherited condition. If your mother or sister has PCOS, you may want to be checked for the syndrome. Monitoring your health is important if you have been diagnosed with PCOS.

If you are overweight, for example, you should have a test to check for your risk of diabetes. The routine fasting blood glucose test is inadequate to diagnose diabetes in all women with PCOS. Instead, the oral glucose tolerance test is considered the "gold standard" as a sensitive tool to assess your risk. This test requires two hours of monitoring your response to sugar.

Because of the possible increased risk of cardiovascular disease in women with PCOS, you should have your blood pressure checked regularly. You should also monitor your levels of bad cholesterol (LDL), good cholesterol (HDL), and triglyceride levels. Vigilance is key if you are overweight.

Staying as healthy as possible is the goal. Try to stay on a healthy diet with adequate amounts of protein, as well as whole grains and lots of fruits and vegetables. Your endocrinologist or doctor should be able to suggest a healthy diet to follow.

Exercise regularly to keep your weight in check, improve your body's response to extra insulin, and reduce your risk of diabetes, heart disease, and stroke.

Finally, be sure to find a specialist who will listen to you and answer your questions. Women with polycystic ovary syndrome sometimes have special concerns about their appearance that are directly tied to their condition. You and your doctor must act as partners to manage all aspects of this complex condition.

With proper diagnosis and treatment, most PCOS symptoms can be reversed or at least managed and your risk of complications greatly minimized.