What is Polycystic Ovarian Syndrome (PCOS)?
Polycystic ovarian syndrome (PCOS) is one of the most common female endocrine disorders. Polycystic Ovarian Syndrome is a complex, heterogeneous disorder of uncertain etiology. Both genes and the environment contribute to Polycystic Ovarian Syndrome.
Obesity, exacerbated by poor dietary choices and physical inactivity, worsens Polycystic Ovarian Syndrome susceptible individuals. It is thought to be one of the leading causes of female subfertility and the most frequent endocrine problem in women of reproductive age.
The principal features are anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries; excessive amounts or effects of androgenic hormones, resulting in acne and hirsutism; and insulin resistance, often associated with obesity, diabetes mellitus type 2, and high cholesterol levels.
Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility):
– The release of excessive luteinizing hormone (LH) by the anterior pituitary gland
– Through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus
Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens.
The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These “cysts” are actually immature follicles, not cysts (“polyfollicular ovary syndrome” would have been a more accurate name).
The follicles have developed from primordial follicles, but the development has stopped (“arrested”) at an early antral stage due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a ‘string of pearls’ on ultrasound examination. There is also an increase in volume of ovary, especially due to increase in stroma.
Women with PCOS have higher GnRH, which in turn results in an increase in LH/FSH ratio.
A majority of patients with Polycystic Ovarian Syndrome have insulin resistance and/or are obese. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to Polycystic Ovarian Syndrome.
Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the development of Polycystic Ovarian Syndrome. Insulin resistance is a common finding among patients of normal weight as well as overweight patients.
Signs and symptoms:
Some common symptoms of Polycystic Ovarian Syndrome include:
– Menstrual disorders: PCOS mostly produces oligomenorrhea or amenorrhea, but other types of menstrual disorders may also occur.
– Infertility: This generally results directly from chronic anovulation (lack of ovulation).
– Hyperandrogenism: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods) or other symptoms. Approximately three-quarters of patients with Polycystic Ovarian Syndrome (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.
– Metabolic syndrome: This appears as a tendency towards central obesity and other symptoms associated with insulin resistance. Serum insulin, insulin resistance and homocysteine levels are higher in women with Polycystic Ovarian Syndrome.
Currently there are no definitive test to diagnose PCOS. A physician will start the work up with past medical history, including menstrual periods and weight changes. A physical exam will include checking for signs of excess hair growth, insulin resistance and acne. The physician may then recommend:
– A pelvic exam: to visually and manually inspects the reproductive organs for masses, growths or other abnormalities.
– Blood tests: to measure hormone levels. This testing can exclude possible causes of menstrual abnormalities or androgen excess that mimics PCOS. Additional blood testing to measure glucose tolerance and fasting cholesterol and triglyceride levels may also be done.
– Transvaginal ultrasound: to checks the appearance of the ovaries and the thickness of the lining of the uterus.
Other causes of irregular or absent menstruation and hirsutism, such as:
– congenital adrenal hyperplasia (21-hydroxylase deficiency)
– Cushing’s syndrome
– androgen secreting neoplasms
Other pituitary or adrenal disorders, should be investigated. Polycystic Ovarian Syndrome has been reported in other insulin-resistant situations such as acromegaly.
Treatment for PCOS focuses on managing the individual concerns, such as infertility, hirsutism, acne or obesity. Specific treatment might involve lifestyle changes or medication.
Lifestyle changes: the physician may recommend weight loss through moderate exercise plus a low calorie diet. Even a small reduction in weight (e.x. losing 5% body weight) may have significant improvement. Losing weight may also increase the effectiveness of medications and can help with infertility.
Medications: to regulate your menstrual cycle, the doctor might recommend:
– Combination birth control pills. Pills that contain estrogen and progestin decrease androgen production and regulate estrogen. Regulating hormones can lower risk of endometrial cancer and correct abnormal bleeding, excess hair growth and acne. A skin patch or vaginal ring that contains a combination of estrogen and progestin may be used instead of pills.
– Progestin therapy. Taking progestin for 10 to 14 days every one to two months can regulate periods and protect against endometrial cancer. Progestin therapy doesn’t improve androgen levels and won’t prevent pregnancy. The progestin-only minipill or progestin-containing intrauterine device is a better choice for individuals who prefer to avoid pregnancy.
To help ovulation, the doctor might recommend:
– Clomiphene (Clomid). This oral anti-estrogen medication is taken during the first part of menstrual cycle.
– Letrozole (Femara). This breast cancer treatment can work to stimulate the ovaries.
– Metformin (Glucophage, Fortamet, others). This oral medication for type 2 diabetes improves insulin resistance and lowers insulin levels. If using clomiphene does not help with pregnancy, metformin may be added to the regimen. Metformin can also slow the progression to type 2 diabetes and help with weight loss.
– Gonadotropins. These hormone medications are given by injection.
To reduce excessive hair growth (hirsutism), the doctor might recommend:
– Birth control pills. These pills decrease androgen production that can cause excessive hair growth.
– Spironolactone (Aldactone). This medication blocks the effects of androgen on the skin. Spironolactone can cause birth defect, so effective contraception is required while taking this medication. It isn’t recommended if the individual is pregnant or planning to become pregnant.
– Eflornithine (Vaniqa). This cream can slow facial hair growth in women.
– Electrolysis. A tiny needle is inserted into each hair follicle. The needle emits a pulse of electric current to damage and eventually destroy the follicle. You might need multiple treatments.