Polycystic ovary syndrome (PCOS) is a condition that affects a woman's cycle, her hormones, her fertility and also her appearance.
Polycystic ovary syndrome is one of the common causes of infertility. Women with the syndrome have many small cysts in their ovaries, which arise because the normal course of the cycle — the growth and maturation of a follicle, then ovulation — is interrupted. The ovary then enlarges and produces large amounts of hormones (androgens and estrogens) which, combined with the fact that ovulation does not occur, cause infertility. Because of this hormonal imbalance, women with polycystic ovaries are statistically more prone to polyps, fibroids and endometriosis.
Twenty out of every 100 women (20%) have polycystic ovaries. In Greece the proportion is perhaps slightly higher. It is very important to stress that having polycystic ovaries does not necessarily mean having polycystic ovary syndrome. Only 6–7% of women with polycystic ovaries also have the syndrome. Those who do have more pronounced symptoms and other health problems.
CAUSES
The cause of the syndrome is not clear. Sometimes it is inherited: if a female relative of yours (mother, aunt, sister) has the syndrome, your own chance of developing it is higher.
SYMPTOMS
Symptoms vary from woman to woman, as does their severity: some women have mild symptoms, others more pronounced ones. In most women with polycystic ovaries the symptoms are mild or negligible. It is only in severe cases of the syndrome that marked hormonal disturbances and other health problems are seen. The main symptoms are as follows:
• irregular periods, or no periods at all • difficulty conceiving (infertility), because the woman does not produce eggs or does not know her fertile days • repeated miscarriages • increased hair growth on the face or body • weight gain, rapid weight gain, difficulty losing weight • oily skin, acne • in severe cases, a male pattern of fat distribution (abdomen, slim legs) • mood changes
Besides the symptoms they experience, women with polycystic ovaries who do not receive appropriate treatment are more likely to develop high blood pressure, heart disease and type II diabetes, as well as other conditions that depend directly on their hormonal system, such as fibroids, endometrial hyperplasia and endometriosis. Polycystic ovaries are also often associated with a family history of high blood pressure, diabetes, infertility, miscarriage or obesity.
The symptoms in detail:
Ovulation problems: anovulation (no ovulation at all) or oligo-ovulation (irregular or infrequent ovulation).
An irregular cycle (because ovulation is irregular): amenorrhea (no periods), oligomenorrhea (infrequent periods, every 2–3 months), polymenorrhea (periods that come very often), menorrhagia (heavy bleeding, or bleeding that lasts many days or weeks) or bleeding between normal periods.
Insulin resistance: the body does not respond to insulin normally. The main function of insulin is to control blood sugar levels. This can show up on certain laboratory tests — for example high fasting insulin levels, a low glucose/insulin ratio, high triglyceride levels and low levels of SHBG (steroid hormone binding globulin).
Hyperandrogenism: androgens are the so-called male hormones. That is misleading, however: everyone, men and women alike, has androgens. It is simply that in men they are present at much higher levels than in women. Women with polycystic ovary syndrome have slightly raised androgen levels, which cause the following symptoms:
• Excess hair growth: usually on the face (upper lip, cheeks, chin, neck) or the body (chest, abdomen, back). • Acne. • Alopecia: the hair thins in the same way as it does in men.
The hormone tests usually recommended to diagnose hyperandrogenism are as follows:
• Total and free testosterone • Dihydrotestosterone (DHT) • Androstenedione • Dehydroepiandrosterone sulfate (DHEA-S)
Women with polycystic ovary syndrome have raised levels on some of these tests.
Ultrasound: in women with polycystic ovary syndrome the following are seen:
• Enlarged ovaries (ovarian volume >10 ml) • A large number (>12) of small follicles (2–9 mm in diameter) just beneath the surface of the ovary, at the periphery • Very few follicles in the centre of the ovary, with dense ovarian stroma (though not necessarily).
Many women can have polycystic ovaries without having polycystic ovary syndrome — in other words, the ultrasound findings alone are not enough to make the diagnosis.
Other findings: some women with polycystic ovary syndrome may also have the following:
• Raised prolactin levels (and a small tip: it is better not to measure prolactin very early in the morning, since levels tend to be higher then — between 10 a.m. and midday is better) • High LH levels • A high LH:FSH ratio • High levels of AMH (anti-Müllerian hormone)
Possible health problems associated with polycystic ovary syndrome
Women with polycystic ovary syndrome have certain health problems more often than the rest of the population, either because the syndrome causes them or because they share the same underlying cause:
• High blood pressure • Type II diabetes • Coronary artery disease • Endometrial cancer (any cause of ovulation problems is associated with an increased risk of endometrial cancer).
Read more here about how polycystic ovary syndrome is currently considered to affect health, according to the consensus statement of ESHRE (European Society of Human Reproduction and Embryology) and ASRM (American Society for Reproductive Medicine):
'Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS)', The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group, Human Reproduction 2004 19(1):41-47. Possible problems during pregnancy in women with polycystic ovary syndrome
• Diabetes during pregnancy • Pregnancy-induced high blood pressure • Preeclampsia • Preterm birth • An increased risk that the newborn will be admitted to intensive care.
DIAGNOSIS
Polycystic ovaries can be diagnosed with an ultrasound scan and by measuring particular hormones in a blood test at the beginning of the cycle. The great problem women with polycystic ovaries have faced until now is that most doctors try to treat a symptom — acne, oily skin, anovulation and so on — rather than the condition itself.
Polycystic ovary syndrome is easy to diagnose in some patients. Their history usually includes an irregular, unpredictable cycle, which may be accompanied by heavy bleeding. They are often overweight, with excess hair on the body and face because of high androgen levels. Some patients, however, may not have these symptoms.
The diagnosis is confirmed with a transvaginal ultrasound, which shows that both ovaries are enlarged and that there are many small cysts, usually at the periphery of the ovary.
As for the hormone profile of these women, in severe cases high levels of androgens (dehydroepiandrosterone sulfate, DHEA-S) and of LH are usually found. FSH is at normal levels. This ratio between FSH and LH is characteristic of polycystic ovary syndrome. Many patients with the syndrome also have high insulin levels, because they are insulin resistant.
It is not clear what causes polycystic ovary syndrome. We do know for certain, however, that the characteristic polycystic ovary develops after a prolonged period without ovulation. These patients have high levels of androgens and LH, which feed the problem further and create a vicious circle. Obesity makes polycystic ovary syndrome worse, because fatty tissue secretes estrogens, which interrupt ovulation.
Read more here about how polycystic ovary syndrome is diagnosed today, according to the consensus statement of ESHRE (European Society of Human Reproduction and Embryology) and ASRM (American Society for Reproductive Medicine):
‘Revised 2003 consensus on diagnostic criteria and longterm health risks related to polycystic ovary syndrome (PCOS)’ The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group Human Reproduction 2004 19(1):41-47
TREATMENT
Polycystic ovaries can be treated today, with medication or with surgery. The therapeutic approach depends on each woman's symptoms and on her primary goal at that point in her life — treating acne or excess hair growth, treating infertility, or managing other health problems caused by the syndrome. For women who are trying to conceive, achieving a pregnancy, with or without ovulation induction, is all that is needed. For women troubled by the symptoms above, the appropriate treatment is decided after laboratory and blood tests. Treatment of polycystic ovary syndrome for infertility focuses on inducing ovulation so that the woman can conceive.
Weight loss and exercise
For many patients, losing weight is by itself an effective treatment. The best strategy is to lose weight gradually but steadily, aiming for a lasting result. Crash diets and very strict regimes that shock the body are not effective. You may need the help of a dietitian. Exercise certainly helps too, because glucose is metabolized better. Aerobic activities such as walking, running or swimming are good choices.
Insulin resistance
We now know that many patients with polycystic ovary syndrome are insulin resistant. The same happens in people with diabetes: insulin levels in the blood are high (hyperinsulinemia) but the body's response to insulin is reduced. These women are given medication (anti-diabetic drugs), which helps restore hormonal balance and improve ovulation.
Surgery
In some cases laparoscopy is needed to treat polycystic ovary syndrome. During the laparoscopy the ovaries are cauterized — that is, the abnormal ovarian tissue is removed, with the aim of restoring normal ovarian function and inducing ovulation. Laparoscopy is necessary when other ways of inducing ovulation have failed. After such an operation about 80% of patients have a normal cycle and 50% of them will conceive within 1 year without further medication or other treatment. One complication of the operation, however, is the formation of adhesions.