CONDITIONS

What Is Polycystic Ovarian Syndrome (PCOS)

Did you know that an estimated 7 million women are living with polycystic ovary syndrome (PCOS) – yet less than half of them have been diagnosed? Also known as Stein-Leventhal Syndrome, PCOS is one of the most common hormonal endocrine disorders in women, and one of the leading causes of infertility. Because symptoms can really vary from woman to woman, and it’s not possible to diagnose the disorder with just one simple test, PCOS is one of the most commonly missed disorders which is why it’s also known as “The Silent Killer.”

The main underlying issue with PSOC is a hormonal imbalance related to a kind of male hormone called androgens. All women produce androgens, but the ovaries of PSOC sufferers over-produce them.  Researchers also believe that insulin may be linked to PSOC – women with PCOS tend to have too much insulin, because their bodies have a hard time metabolizing it. There is a link that shows excessive insulin appears to lead to excessive production of androgens.

Recognized and diagnosed only for the past 75 years, the most common effect of PCOS is enlarged ovaries containing small amounts of fluid, called follicles (or cysts), in a “string of pearls” pattern, which can been seen during ultrasound exams. (“Polycystic” means “many cysts.”) However, these follicles don’t present on every woman with PCOS. A common cause of infertility, PCOS can cause infrequent menstrual periods or prolonged periods. This hormonal disorder can also cause insulin resistance (a prime indicator of PCOS), as well as symptoms related to increased testosterone levels, including excessive hair growth (hirsutism), male pattern baldness, and failure to ovulate monthly. Weight gain, difficulty losing weight, and acne are also symptoms.

In teenagers, a warning sign for PCOS is absent or infrequent menstruation. Early diagnosis is important, because PCOS is linked to an increased risk of developing several medical risks, especially if obesity is also a factor – these risks include the development of type 2 diabetes, heart disease, and several types of cancer.

Five to 10 percent of women of childbearing age are affected by PCOS, and it’s responsible for 70 percent of infertility issues in women who have difficulty ovulating. PCOS can occur in girls as young as 11, and post-menopausal women can also suffer from PCOS.

There is no cure for PCOS, but the good news is it can be managed and treated to prevent problems, and the health risks can be mitigated.

What Causes Polycystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome is an endocrine – or hormonal – disorder – it’s essentially a set of symptoms related to a hormonal imbalance. Doctors currently do not know exactly what causes PCOS, but there are several risk factors that may play a role:

Genetics. Women with PCOS are more likely to have a mother or sister with PCOS – some studies have found that if a mother has PCOS, there is a 50 percent chance that her daughter will have it as well. Researchers are also exploring the possibility that there is a gene related to PCOS.

Excess insulin. If you have insulin resistance, that means your body’s ability to use insulin is impaired, which leads to excess insulin. This in turn may cause your ovaries to increase their production of androgens (a male hormone that even healthy women produce, but in very small amounts). Increased androgen levels, among other things, can interfere with the ovaries’ ability to ovulate. Additionally, studies have shown that approximately 40 percent of female patients with diabetes and/or glucose intolerance between the ages of 20-50 have PCOS.

Low-grade inflammation. Inflammation is our body’s way of fighting infection, whereby white blood cells create an infection-fighting substance. Research has shown that some women with PCOS maintain a level of low-grade inflammation, which can in turn stimulate polycystic ovaries to produce androgens.

Diagnosing Polycystic Ovarian Syndrome (PCOS)

There is no single test to diagnose PCOS, so, when diagnosing PCOS, a doctor will need to rule out other causes for your symptoms. Your primary care physician may refer you out to gynecologist, an endocrinologist, or a reproductive endocrinologist. Medical professionals will look for a least two of the following main symptoms:

Irregular periods.  The most common characteristic of PCOS, this can mean intervals of at least 35 days between periods, failure to menstruate for at least four months in a row, or having fewer than eight menstrual cycles a year.  It can also mean prolonged periods (light or heavy) that last for days.

Excess androgen. Raised levels of androgens (male hormones) can result in physical symptoms, such as hirsutism (excessive facial or body hair), severe adolescent acne or adult acne, skin tags and dark patches of skin, and thinning hair or male pattern baldness.

Raised hormone levels can also manifest in other health concerns, including weight gain, increased cholesterol, and high triglycerides.

Polycystic ovaries. Ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs, called follicles or cysts.  In a healthy woman, as the egg grows, the follicle builds up fluid, and when the egg matures, the follicle breaks, releasing the egg to travel through the fallopian tube to the uterus where it can be fertilized.  This is called ovulation. However, in women with PCOS, the ovary doesn’t make the right mix of hormones for the egg to fully mature, so, though the egg does start to grow, and the fluid does build up, it’s not always released. Some follicles remain as cysts, and since ovulation does not occur, the hormone progesterone is not made, and the menstrual cycle is irregular or absent. These follicles, or cysts, can often be seen on an ultrasound.

Because of the increased presence of androgens, polycystic ovaries become enlarged, containing numerous small fluid-filled cysts, which surround the eggs.

To diagnose PCOS, these are the methods used:

  • Medical history. Your doctor will want to detailed gather information about your menstrual cycle, your pregnancy history or infertility issues, any weight changes, sleep patterns, fatigue or depression. Your doctor will also want to know about your family history, and any other physical symptoms you’ve been experiencing (as well as how long you’ve been experiences them, and when they started).
  • Physical exam. Your doctor will want to measure your body mass index (BMI), your waist size, and your blood pressure. He or she will also want to examine any other physical symptoms, such as skin tags and areas of excessive hair growth.
  • Pelvic exam. A pelvic exam might show your doctor if your ovaries are enlarged, or if there is the presence of cysts.
  • Vaginal ultrasound/sonogram: A sonogram (or ultrasound), allows your doctor to see pictures of your pelvic area by the use of sound waves. This can reveal the presence of tiny cysts on your ovaries, which, when grouped together in the classic presentation for PCOS, look like pearls. Ultrasounds are also used to check the endometrium (lining of the womb), which can become thicker if your periods are not regular.
  • Blood tests. Blood tests can show your androgen levels (including testosterone) as well as your glucose (blood sugar) levels.

It’s important to diagnose PCOS because, untreated, it can lead to a variety of medical problems, including:

  • Infertility
  • Abnormal uterine bleeding
  • Cancer of the uterine lining (endometrial cancer). Irregular menstrual periods and the lack of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Progesterone is important, because it causes the endometrium (the lining of the uterus) to shed each month – that’s your menstrual period. Without progesterone, the endometrium doesn’t shed, and it becomes thick. This can cause heavy or irregular bleeding, and, over time, lead to endometrial hyperplasia (when the lining grows too much), and cancer.
  • Insulin resistance
  • Gestational diabetes (pregnancy-induced high blood pressure)
  • Type 2 diabetes. More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance)
  • High cholesterol
  • High blood pressure
  • Metabolic syndrome
  • Heart disease. The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
  • Non-alcoholic steatohepatitis (a severe liver inflammation caused by fat accumulation in the liver)
  • Sleep apnea
  • Depression
  • Anxiety

Symptoms of Polycystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome can create many symptoms, all of which are related to, or are complications from, the hormonal imbalances that comprise the syndrome. Symptoms often start to present after a woman first begins having periods (also known as menarche), but some women can develop PCOS symptoms later during the reproductive years. Symptoms, which can worsen with obesity, can vary from person to person; which is one of the reasons why diagnosing PSOC can be difficult.

The symptoms of PCOS can include:

  • Infertility
  • Infrequent, absent, and/or irregular menstrual periods (oligomenorrhea)
  • Multiple follicles (cysts) on the ovaries
  • Pelvic pain
  • Fatigue
  • Sleep apnea
  • Weight gain, obesity, and/or difficulty losing weight (usually with extra weight around the waist)
  • Hirsutism (excess hair growth on face and body, including chest, stomach, back, thumbs, or toes)
  • Skin tags (excess flaps of skin in the armpits or neck area)
  • Darkened patches of skin (acanthosis nigricans) on the neck, arms, breasts, or thighs
  • Thinning hair (male pattern balding)
  • Acne, oil skin, or dandruff
  • High cholesterol and high triglycerides
  • Increase in stress levels
  • High blood pressure
  • Insulin resistance
  • Type 2 diabetes
  • Depression
  • Anxiety
  • Decreased sex drive

Prognosis

Women with PCOS appear to have higher rates of:

  • Miscarriage
  • Gestational diabetes
  • Pregnancy-induced high blood pressure (preeclampsia)
  • Premature delivery

Babies born to women with PCOS have a higher risk of spending time in a neonatal intensive care unit or of dying before, during, or shortly after birth. However, it’s important to note that most of the time, these problems occur in multiple-birth babies (twins, triplets, etc.), which are often the result of fertility treatments.

Researchers are studying whether a diabetes medicine called metformin can prevent or reduce the chances of complications during pregnancy for women with PCOS. Metformin, and FDA pregnancy category B drug, lowers male hormone levels and limits weight gain in women who are obese when they get pregnant. It does not appear to cause major birth defects or other problems in pregnant women, but there have only been a few studies of metformin use in pregnant women to confirm its safety.  It’s important to discuss taking metformin with your doctor if you are pregnant or are trying to conceive. It’s also important to know that metformin is passed through breast milk, so talk with your doctor about metformin use if you are a nursing mother.

While specific fertility issues should be addressed with your physician, according to The Cleveland Clinic, there are some general healthcare guidelines that may improve your chances of becoming pregnant:

  • Folic acid (400 mcg. supplement a day, with a diet rich in folic acid, including leafy green vegetables, dried beans, liver, and citrus fruits)
  • Limit caffeine (fewer than two caffeinated beverages per day)
  • Eat well (healthy, well-balanced diet)
  • Exercise and maintain a healthy weight (maintain a normal exercise routine, 20 to 30 minutes per day, 4 to 5 times per week.)

Living With Polycystic Ovarian Syndrome (PCOS)

In addition to the health issues that can come along with PCOS, the physical symptoms can also be upsetting.  If you are living with PCOS, know that you are not alone– seek out support groups, and if depression or anxiety are an issue, you can get help and support. Explore all your options for treatment.  The PCOS Foundation is a good place to start: http://pcosfoundation.org

Prevention

Since it is not known what caused PCOS, there is no known method of prevention. The good new is that through proper treatment and lifestyle behaviors, many women with PCOS can avoid developing medical issues such as cardiovascular problems, diabetes, and uterine cancer.

Common Treatment

While there is no cure for PCOS, it can be managed to prevent problems through lifestyle changes and medications to address the symptoms. Treatment is usually focused to manage your main concerns, whether that’s infertility, obesity, hirsutism, acne, or any of the effects of PCOS.

Lifestyle

  • Weight loss. As a first step, your doctor may recommend weight loss through healthier eating and an increase in exercise. Even a modest amount of weight loss, such as five percent of your body weight, can improve your condition. Importantly, losing weight helps to lower your blood glucose levels and improve your body’s use of insulin. Losing weight can also help normalize your hormone levels. A ten percent loss in body weight can make your cycle more regular and restore a normal period.
  • Improving your diet. Because low-fat, high-carb diets are believed to increase insulin levels, a low-carb diet is something to consider if you have PCOS, and if your doctor recommends it. Completely avoiding, or even severely restricting, carbohydrates is not advised; rather, it’s better to work a moderate amount of complex carbohydrates, which are high in fiber, into your diet. High-fiber foods are digested more slowly, which means they cause your blood sugar levels to rise more slowly than low-fiber foods like simple carbs (such as cake, candy, juice, soda, ice cream, cookies, etc.). Examples are complex carbs include whole-grain cereals and breads, bulgur wheat, brown rice, barley, and beans.
  • Increasing your activity levels. Exercising helps lower your blood sugar levels – if you have PCOS, regular exercise can treat or even prevent insulin resistance. It will also help you keep your weight under control. Plus, it’s also heart-healthy, and can mitigate feeling of depression or anxiety.

Medications

Medications may be prescribed to…

  • Regulate your menstrual cycle:  If you’re not trying to get pregnant, your doctor may recommend combination birth control pills. Combination birth control pills contain both estrogen and progestin, which will decrease your androgen production and give your body relief from the effects of continuous estrogen production. This, in turn, lowers your risk of endometrial cancers and can correct abnormal bleeding.  As an alternative to a daily pill, your doctor can prescribe a skin patch or vaginal ring containing the combination of estrogen and progestin. While on any of these treatments, you will not be able to conceive.

If for any reason you’re not a good candidate for combination birth control pills, another approach is to take progesterone every day for 10-           14 days, every one or two months. This progesterone therapy can regulate your periods and decrease your risk of endometrial cancer, but it           does not improve your androgen levels, and it will not prevent pregnancy.

Your doctor may also prescribe a metformin (such as Glucophage, Fortamet, and others), which is an oral medication for type 2 diabetes               that improves insulin resistance and lowers insulin levels. Taking this drug may help with ovulation and lead to regular menstrual cycles.               Additionally, if you are pre-diabetic, Metformin slows the progression to type 2 diabetes and aids in weight loss (if you also follow a diet                 and an exercise program).

Help you ovulate / address infertility:  Fertility problems in women with PCOS usually stem from a lack of ovulation, so fertility medications may be prescribed. These include:

  • Clomiphene (Clomid, Serophene) — is an oral anti-estrogen medication that you take in the first part of your menstrual cycle. It’s usually the first choice of therapy to stimulate ovulation for most patients.
  • Metformin combined with clomiphene — if clomiphene alone fails, this combination may help women with PCOS ovulate on lower doses of medication.
  • Gonadotropins — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) medications that are administered by injection may be used if the above options don’t work.
  • Letrozole (Femara) — doctors don’t know exactly how letrozole works to stimulate the ovaries, but, when other medications fail, it may help with ovulation.
  • IVF — in vitro fertilization is also an option, as it offers the best chance of becoming pregnant in a given cycle, but it is extremely costly.

All of the above fertility therapies come with the risk of multiple births, and should always be undertaken under the supervision of a reproductive specialist.

Reduce excessive hair growth. Birth control pills may be recommended to decrease androgen production, which can in turn reduce excessive hair growth. Another medication, spironolactone (Aldactone), blocks the effects of androgens on the skin, but because spironolactone can cause birth defects, effective contraception is required when using the drug. It’s of course not recommended if you’re pregnant or planning to become pregnant. The cream Eflornithine (Vaniqa) is another option, as it slows facial hair growth in women.


Surgery and procedures

There are several surgeries and procedures that may be recommended to treat the symptoms of PCOS. All of these procedure option should be thoroughly discussed with your doctor:

“Ovarian drilling” is a surgical treatment used to trigger ovulation in women who have PCOS. IT is employed when a woman is not responding to fertility medicines, after having lost weight to lessen the effects of her PCOS. The goal of the procedure is to restore ovulation cycles, and lower male hormone levels. During the laparoscopic procedure, a doctor inserts either  a laser or small electrocautery tool into the abdomen, through a small incision above or below the navel, which carries an electrical current that punctures the ovary and destroys a small portion of it.  The surgery does carry the risk of developing scar tissue on the ovary, and it is important to note that the benefits are not permanent – they will generally last a few months to a couple of years. Typically, cycles become irregular again over time.  This treatment does not address the issues of excess body hair or thinning hair on the scalp.

Oophorectomy. Done only when other treatment methods have failed, and only if the woman is either past childbearing age, or does not want to have children, an oophorectomy is a surgical procedure where one or both ovaries are removed, which therefore will reduce or eliminate the hormones that your body receives from your ovaries. If both ovaries are removed, this is called a bilateral Oophorectomy. This surgery is generally performed along with other procedures, such as a hysterectomy.  Both this procedure and a hysterectomy can manage the hormonal symptoms of PCOS, but would not be recommended for a woman trying to conceive. There are significant risks with this surgery and should only be considered for those with severely symptomatic PCOS, and should be discussed at length with your doctor.

Hysterectomy. Done only when other treatment methods have failed, and only if the woman is either past childbearing age, or does not want to have children, in a hysterectomy, a doctor removes a woman’s uterus and cervix. If only the uterus is removed, it’s called a partial hysterectomy. This will send a woman into instant menopause, and can come with other significant risks. Hysterectomy should only be considered for those with severely symptomatic PCOS, and should be discussed at length with your doctor.

Laser hair removal or electrolysis. Laser hair removal or electrolysis can be recommended to remove unwanted body hair.

When To Contact A Doctor

If you are experiencing any of the symptoms of PCOS, it’s important to contact your doctor. Diagnosis is vital, because while unchecked PSOC can lead to severe health complications, it’s very possible to manage the symptoms through proper treatment and lifestyle changes!

Questions For A Doctor

When you go to see your doctor, it’s good to be prepared with as much information as possible about your symptoms that you can share with your doctor, including information about your menstrual cycles, fertility issues or pregnancies, and your family history. According to the Mayo Clinic, your doctor might ask you any of the following questions:

  • What signs and symptoms is you experiencing?
  • How long have you been experiencing each of these symptoms?
  • How often do you experience these symptoms? How severe are they?
  • When was your last period? How long are your cycles typically
  • Have you gained weight since you first started having periods?
  • Does anything improve your symptoms?
  • Does anything make your symptoms worse?
  • Are you trying to become pregnant, or do you wish to become pregnant?
  • Has a close female relative (grandmother, mother, sister, aunt) ever been diagnosed with PCOS?

It’s also good to have a list of the questions you’d like to have answered. Take a moment to write down some of the things you want to know. Your questions for your doctor might include some of these:

  • What kinds of tests might you recommend for me?
  • I have other medical conditions. How can I best manage them together?
  • What types of lifestyle changes do you recommend for me?
  • What treatment do you recommend for my particular situation and symptoms?
  • How does PCOS affect my fertility?
  • What medications exists that might improve my symptoms, or improve or my ability to conceive?
  • What side effects can I expect from any medication use?
  • What are the long-term health implications of PCOS for me?
  • Do you have any brochures or other printed materials that I can take with me?
  • Do you recommend any websites or resources?

Resources

For support, information, and resources, visit the PCOS Foundation: http://www.pcosfoundation.org

Their mission is to spread awareness through public and professional education programs in order to improve diagnosis and decrease or eliminate the lifetime risks associated with PCOS (Polycystic Ovarian Syndrome).

Additionally, The Office on Women’s Health, U.S. Departments of Health and Human Services, has a great list of resources:

American Association of Clinical Endocrinologists (AACE)
Phone: 904-353-7878

American College of Obstetricians and Gynecologists
Phone: 202-638-5577

American Society for Reproductive Medicine (ASRM)
Phone: 205-978-5000

InterNational Council on Infertility Information Dissemination, Inc. (INCIID)  
Phone: 703-379-9178

Women’s Health Research, National Institute of Child Health and Human Development, NIH, HHS  
Phone: 800-370-2943