What is Polycystic Ovarian Syndrome (PCOS)?

An estimated four to six percent of women of childbearing age have PCOS. It is the most common endocrinopothy of women. If a women has two of the three following characteristics, they have poly cystic ovary snydrome.:

1. Evidence of anovulation or irregular menstral cycle.
2. Evidence of hyperandrognemia either clinically or biochemically means there is evidence of elevated male hormone production. This is measured by a blood test that measures testosterone level. Another indication is hirsutism or hair growth issues, which is abnormal hair growth in hormonal dependent areas, including the upper lip, the chin, the face, the breast and the lower abdomen. It can be very mild to very severe.
3. When you have a poly cystic ovary appearance on a transvaginal pelvic ultrasound, the image looks like tiny cystlike formations. They are eggs or follicles rimming the ovaries, starting to grow and then stopping at a small follicle size of apprximately 2-10 mm. This appearance is very characteristic and can be used for making a diagnosis.
4. Of note, when making the diagnosis of PCOS other medical conditions that present like PCOS must be eliminated. The following hormone conditions must be ruled out prior to making the diagnosis of PCOS: thyroid disease, ovarian and/or adrenal tumors, adrenal enzyme deficiency and prolactin abnormalities.

• High levels of male hormones, also called androgens. This can cause excessive facial and body hair or hirsutism
• An irregular or absent menstrual cycle
• May or may not have many small cysts in their ovaries as seen on an ultrasound
• Inability to get pregnant
• Acne, oily skin
• Weight gain or obesity, usually carrying extra weight around the waist
• Difficulty losing weight
• Type 2 diabetes
• High cholesterol, high triglyceride levels
• High blood pressure
• Patches of thickened and dark brown or black skin on the neck, arms, breasts or thighs (acanthosis nigricans)
• Sleep apnea -- excessive snoring and interrupted breathing while sleeping
• An important reason to recognize PCOS, is that it can put a person at risk for insulin resistance syndrome type medical issues. You can develop a high risk for Type 2 Diabetes, high cholesterol, high triglyceride levels and high blood pressure. A woman can also be at risk for endometrial cancer or abnormal growth of the lining of the uterus. This is why it is important for people with PCOS to be treated medically and have their irregular cycles addressed

What causes Polycystic Ovarian Syndrome?

The exact cause of PCOS is not known. There is an inheritable component to PCOS which means women with the condition frequently have a mother or sister with PCOS. There is a fifty percent chance of getting PCOS if your mother has the condition. Many women with PCOS have a weight problem, so researchers are looking at the relationship between PCOS and the body's ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches and other food into energy for the body's use or for storage. Women with PCOS make too much insulin causes the ovaries to react and make too many male hormones. Insulin also disrupts how you make eggs, creating irregular cycles. The disruption in normal functioning of the ovary in PCOS can lead to acne, excessive hair growth, weight gain and ovulation problems.

What tests are used to diagnose PCOS?

Various tests will be done to diagnose PCOS. Your doctor will take a medical history, perform a physical exam and check your hormone levels by looking at the thyriod, pituitary and adrenal hormone levels. You may have your glucose metabolism and diabetes risks levels tested which is done with an oral two hour glucose tolerance test and a fasting insulin.

A vaginal ultrasound may be performed to examine the ovaries for cystic appearance and to evaluate the lining of the uterus (or endometrium).

Why do women with PCOS have trouble with their menstrual cycle?

Each month, a collection of multiple eggs start to mature in a woman's ovaries but usually only one becomes mature or dominant. In women with PCOS, the ovary doesn't receive the correct signals from the pituitary to produce the hormones it needs for any of the eggs to fully mature. Some researchers think this is because of high insulin levels which interrupts the normal signals to grow eggs. Follicles containing eggs start to grow but do not receive the correct signals. The follicles stop growing or arrest and become atretic remaining as small cystic areas seen on ultrasound. Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman's menstrual cycle is irregular or absent. The small arrested or atretic follicles produce male hormones with contribute to the symptoms of PCOS.

How is PCOS treated?

There is no cure for PCOS, so it needs to be managed to prevent problems. Treatments are based on each individual case. Following are descriptions of treatments used for PCOS. How we treat PCOS is dependent on what the goal is:

Lifestyle. This is the most important factor for long term health. Exercise is key. Women with PCOS, need to exercise more than an average routine of regular areobic exercise. The Institute of Medicine recommends one hour of areobic exercise each day. It does not have to be done at one time. It could be, for example, broken into two thirty-minute routines each day, but exercise is key. In addition, diet is important to lifestyle changes.

A healthy weight. Women who maintain a healthy weight, can help manage PCOS. Since obesity is common with PCOS, a healthy diet and physical activity help maintain a healthy weight. This can help the body lower glucose levels, regulate insulin levels and may help restore a normal period. Even loss of 10% of your weight can help make your cycle more regular. Two things to look at when evaluating a diet are quantity issues and quality of the diet. Portion sizes need to be decreased. Losing weight is important if someone is overweight. Seeing a nutrionist can be helpful in this area. Quality of the diet means it is important to stay away from simple carbohydrates. Complex carbohydrates such as fresh fruits, vegetables and grains are key.

Birth control pills. For women who don't want to become pregnant, birth control pills can regulate your cycle. Birth control pills contain two hormones. One is a progesterone-like drug that can regulate menstrual cycles, and suppress the ovaries to reduce male hormone levels and help to clear acne. The other is estrogen. Estrogen works at the liver and produces proteins which bind male hormones (like a sponge and it soaks up) thereby, decreasing the male hormone levels. If you stop taking the birth control pills, the menstrual cycle will become abnormal again.

Progestins (Medroxyprogesterone acetate, Provera). Women may also consider taking a medication that contains only a progesterone-like drug. This medicine will help regulate the cycle and prevent endometrial problems. Progesterone alone does not help reduce acne and hair growth.

Antiandrogens (spironolactone). If a woman is not trying to get pregnant some other medications in addition to birth control pills may reduce hair growth by blocking male hormone action. Other non-medical treatments such as electrolysis or laser hair removal are effective at getting rid of unwanted hair. If the underlying medical problem of hair growth is not addressed, even with treatment of electrolysis or laser hair removal, new hair follicles will grow and unwanted hair will remain a problem.

Diabetes medications. Certain medicines which are used to treat type 2 diabetes, also helps with PCOS symptoms. They reduce insulin levels and decreases the testosterone production. Abnormal hair growth will slow down and ovulation may return after a few months of use.

Fertility medications. The main fertility problem for women with PCOS is lack of ovulation. There are various fertility medications available. Clomiphene citrate. The most common medication used for treating anovulation (lack of ovulation causing infertility), is Clomiphene citrate. Clomiphene citrate stimulates the pituitary to produce better egg growth. Some side effects with Clomiphene citrate include hot flashes, vaginal dryness, moodiness, ovarian cyst formation and abdominal bloating. PCOS patients are at increased risk for multiple births (7-10%). Treatment with clomiphene usually starts at the lowest dose of medication and adjusting the dose each month until ovulation is achieved. Some women do not respond well to Clomiphene citrate. In these women alternative medications can be used including the addition of metformin and/or the use of aromatase inhibitors.

In women who do not respond to clomiphene, another therapy is the use of Gonadotropins which are medicines that contain the active component, follicle stimulating hormone or FSH, which is the hormone which the body makes to help an egg grow. The chance of multiple births is higher (20-25%). Careful monitoring is needed so to make sure the proper amount of eggs are being produced. Also, overstimulation can cause Ovarian Hyper Stimulation Syndrome (OHSS). This is a potentially serious problem where the ovaries become quite enlarged and fluid collects in the abdomen. Patients may have diffuculty eating breathing and walking. Hospitalization is sometimes required.

In vitro Fertilization is sometimes recommended to as a treatment of PCOS. A woman is given medicine to help grow eggs. The eggs are then retrieved and fertilized in a dish. Then the embryos are placed back into the uterus. This procedure helps to control the risk of multiple births.

Surgery. Although it is not recommended as the first course of treatment, a process known as ovarian drilling is available to induce ovulation. This procedure carries the risk of developing scar tissue on the ovary. This surgery can lower the male hormone levels and help with ovulation. Unfortunately, these effects may only last a few months. This treatment does not help with increased hair growth and loss of scalp hair.

Does PCOS put women at risk for other conditions?

Women with PCOS can be at an increased risk for developing other conditions. Irregular menstrual periods and the absence of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Without progesterone, which causes the endometrium to shed each month as a menstrual period, the endometrium becomes thick, which can cause heavy or irregular bleeding. Eventually, this can lead to endometrial hyperplasia or cancer. Women with PCOS are also at higher risk for diabetes, high cholesterol, high blood pressure and heart disease. Getting the symptoms under control at an early age may help reduce this risk.

For more information about PCOS, visit these web sites:

http://pcosupport.org

http://androgenexcesssociety.org

http://asrm.org