Polycystic ovary syndrome

Also known as polycystic ovarian syndrome (PCOS), stein-leventhal syndrome

As the name suggests, it is a hormonal condition in which the ovaries are enlarged and contain many small, fluid-filled cysts. It is relatively common with approximately 5-10% of women having PCOS.

Symptoms can include obesity, irregular menstrual periods or heavy bleeding, acne, excessive hair growth and for some women it can be harder to get pregnant. Some women have no symptoms. Treatments range from hormonal therapies through to surgery. Women with PCOS are at higher risk of developing type 2 diabetes and/or heart disease so it is important to do all you can to lower this risk. Key lifestyle changes that help include not smoking, maintaining a healthy body weight, healthy eating and keeping physically active.

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What is PCOS?

PCOS occurs when your ovaries produce more of the male hormones (androgens) than normal. This leads to an imbalance in the male and female hormones in the body. During the normal monthly menstrual cycle, many small follicles (sacs) grow in your ovaries and form eggs. At mid-cycle, or ovulation, an egg is released from one of the ovaries and all the other follicles 'over-ripen' and break down. However, in PCOS, ovulation does not occur and an egg is not released. The follicles do not break down, but fill with fluid and turn into cysts. The ovaries can then swell in size, sometimes becoming two to five times larger than normal.

How common is PCOS?

PCOS is the most common endocrine disorder in younger women with approximately 5 to 10% of women age 18 - 44 thought to have PCOS.

Causes

The cause is not yet fully understood. There appear to be a number of components, including genetics, obesity, insulin resistance and others.

While insulin resistance and the resulting hyperinsulinemia (high levels of insulin in the blood stream) are responsible for the majority of the changes found in PCOS, there are complex interactions occurring across many body systems. We do know though, that if insulin levels in the blood are too high, the ovaries react by producing more male hormones.

Symptoms

Symptoms of PCOS vary from person to person and tend to appear in the 20's or 30's.

Common symptoms include some or all of the following:

  • Acne.
  • Excessive hair growth on the face, chest or abdomen (hirsuitism).
  • Hair loss or thinning (in a classic 'male baldness' pattern).
  • High blood pressure.
  • Infertility - problems getting pregnant.
  • Irregular or absent periods.
  • Obesity, particularly around the middle.
  • Symptoms of diabetes, such as thirst, going to the toilet more than normal, skin infections or vaginal thrush (candidiasis).

Diagnosis

There is no easy test for PCOS, so your doctor will need to assess your symptoms, your medical history and physical appearance.

If your doctor suspects you have PCOS, he or she will probably arrange tests to confirm it and rule out other more serious medical conditions. These tests may include:

  • an ultrasound scan to give a view of your ovaries
  • blood tests to check your levels of male hormones, insulin, glucose, cholesterol or luteinising hormone (which stimulates ovulation).

About 20% of women (pre-menopause) are shown to have polycystic ovaries on ultrasound yet may have no symptoms of PCOS itself.

Treatment

PCOS is treatable, but not curable. The key is learning what you can do to help yourself as exercise and weight loss (if overweight as most people with PCOS are) are the secret weapons for managing PCOS.

A recent review confirmed that:

"Weight loss through life style changes, preferably a low calorie diet, should be the first line treatment in overweight/obese women with PCOS. Metformin can be considered as an additional treatment but has a subtle additive effect."

Medications

Progestogen - you may be prescribed progestogen (a synthetic version of the female hormone progesterone) or the contraceptive pill to induce regular periods.

Contraceptive pill - some low-dose contraceptive pills contain oestrogen and a small amount of the anti-androgen (a substance which blocks the effects of male hormones) cyproterone acetate. This is very effective in keeping excess hair growth under control and improving acne.

Cyproterone acetate - is also available by itself and your doctor may suggest you try this or another anti-androgen, spironolactone, which works in a similar way. Sometimes excessive hair growth is best managed with both medical treatment and electrolysis or laser therapy. Your doctor can advise what’s best for you.

Isotretinoin - is used for severe acne that hasn’t been helped by other treatments. It works by reducing the amount of oil the skin produces and shrinking the oil glands in the skin. It is usually prescribed by a specialist doctor as it has numerous side effects. It should not be used in pregnancy or if you might become pregnant as there is a high risk of permanent damage to the unborn baby.

Metformin - drugs such as metformin, which helps your body make better use of the insulin it produces, may also be prescribed. These medicines help women with PCOS lose weight, reduce blood pressure and can often restore the menstrual cycle, as well as helping control excess body hair caused by high testosterone levels.

With all these medicines, it's important to remember they may take some time to work. Also, you will need to remove any existing hair growth manually using a method such as bleaching, waxing or electrolysis, as the medicines do not do this.

Fertility treatment can include the use of drugs such as clomiphene citrate (which stimulates the ovary to grow follicles so that an egg is released mid-cycle), or injections of synthetic hormones similar to the naturally produced hormones.

Surgery

As a treatment for infertility, your doctor may suggest surgery called laparoscopic ovarian drilling, which uses either a hot needle or laser to cauterise the ovary in several places. This procedure can stimulate ovulation and increase the chances of conceiving. However, surgery is generally considered a last option because scar tissue can form on the ovaries as a result, which may in fact further reduce your ability to get pregnant in the future.

Complications

PCOS can increase your chances of developing health problems later in life, so it is important to have regular medical check-ups. Even though some PCOS symptoms may lessen after the menopause, this is likely to be the time many of the long-term associated conditions appear.

These can include the following:

Type 2 diabetes. The difficulty most women with PCOS have in processing insulin tends to get worse with age. By the time of menopause, about 50% of women with PCOS are diagnosed with type 2 diabetes. Because of this, it is important to follow a healthy diet and maintain an exercise programme long before menopause.

High blood pressure and increased risk of heart disease - ask your medical clinic at what age you should start having cardiovascular risk assessments and have your blood pressure checked regularly.

Increased cholesterol levels. High levels of testosterone can cause the levels of LDL-cholesterol (so-called ‘bad’ cholesterol) in your blood to go up, resulting in an increased risk of heart disease and heart attack. Women with PCOS can also have reduced levels of HDL-cholesterol (the 'good' form of cholesterol) and raised triglycerides (another form of fat in the blood).

Endometrial cancer. Because women with PCOS do not ovulate often, they have infrequent periods, which results in a build-up of the lining of the uterus (endometrium). This may increase the risk of the uterine lining producing abnormal cells that can turn into cancer, although this is not known for certain.

Self care

Early recognition of the symptoms of PCOS and working on reducing insulin resistance through diet and exercise can help prevent complications of PCOS, including infertility. Weight loss and exercise alone can help some women with PCOS become pregnant. Talk with your doctor and nurse about what else you can do to normalise your insulin levels and keep your cholesterol levels at an acceptable level.

Learn more

Polycystic ovary syndrome (PCOS) Southern Cross Healthcare Group, 2013

References

  1. Understanding polycystic ovary syndrome - Best Practice Journal (BPJ) and Best Practice Advisory Centre NZ (bpacNZ), 2008
  2. Azziz R, Woods KS, Rayna R et al. The Prevalence and Features of the Polycystic Ovary Syndrome in an Unselected Population. J Clin Endocrinol Metab 2004;89(6):2745-2749
  3. Ravn P1, Haugen AG, Glintborg D. Overweight in polycystic ovary syndrome. An update on evidence based advice on diet, exercise and metformin use for weight loss.  Minerva Endocrinol. 2013 Mar;38(1):59-76
Credits: Health Navigator March 2014.