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Polycystic Ovary Syndrome (PCOS) - Your Questions Answered
Author: Dr. Anna Kaplan
What is polycystic ovary syndrome?
Polycystic ovary syndrome is a fairly common problem affecting as many as 5 to 10 percent of women during their child-bearing years. As the name suggests, it has to do with cysts on the ovaries and problems related to what probably causes the cysts. In addition to cystic ovaries, women with PCOS usually do not have regular periods because they do not ovulate (release an egg from the ovaries) every month. They often have evidence of excess male hormones.
What are the usually symptoms of PCOS?
Most women with PCOS have irregular and infrequent periods, usually less than eight periods a year. Because of irregular ovulation, women with PCOS often have trouble getting pregnant. The effects of the excess male hormone, testosterone, include acne as well as growth of facial and other body hair. At the same time, women with PCOS may experience thinning of scalp hair. They may be overweight, sometimes very overweight to the point of obesity. These problems are all interrelated.
How do doctors make the diagnosis of PCOS?
Women with the classic signs and symptoms of PCOS are easy to diagnose. However, there is a spectrum of PCOS disease, and experts have tried to come up with criteria that would allow doctors to diagnose cases that are not typical. One such set of criteria states that women with PCOS must have at least two of the following problems:
- Irregular ovulation or no ovulation
- Visible evidence of excessive male hormones or laboratory tests showing excess male hormone
- Ovaries with multiple cysts in them – at least 12 cysts in an ovary.
Many women experience all three of these problems.
Not all doctors agree with these criteria because a woman can be diagnosed with polycystic ovary syndrome and not have polycystic ovaries.
In addition to infertility, what medical problems are associated with PCOS?
Women with PCOS are often overweight, even obese. They may develop signs and symptoms of what is called “the metabolic syndrome.” This can include a high BMI (body mass index), as well as a large waist circumference (more than 35 inches). It can also include high blood pressure. Women with PCOS may have a number of laboratory abnormalities, including the levels of certain types of cholesterol and other fats. Women with PCOS may have abnormal blood sugar levels, either when fasting or after a challenge test, which checks the blood sugar after a woman drinks a sugary liquid.
A key part of the metabolic syndrome is that the body is insensitive to insulin, the hormone needed in order for the body to use glucose properly. Insensitivity to insulin causes trouble metabolizing glucose, sometimes to the point of actual diabetes with elevated blood sugars.
It is thought that insulin insensitivity may be one of the causes of many of the abnormalities in PCOS. Research is active in this area.
People with the metabolic syndrome or parts of it, such as high blood pressure or diabetes, have an increased risk of heart disease, stroke, and other cardiovascular problems. Treatment of the metabolic syndrome in general lowers the risk of developing other diseases. It is likely that treatment of women with PCOS and the metabolic syndrome will lower their risk of these other disorders as well as improving their fertility.
How is PCOS treated if the patient is not trying to get pregnant?
Birth control pills are often used to regulate the menstrual periods. Some birth control pills can also minimize the effects of excess male hormone and cause a decrease in facial and body hair as well as acne.
Other medicines can be added to counteract the effects of testosterone. This includes a medicine which decreases excess body hair as well as a second medicine that can reduce scalp hair loss. These drugs must not be taken by women who might become pregnant. There are creams that can decrease the appearance of facial hair, as well as many standard treatments for acne.
Because so many women with PCOS have the metabolic abnormalities described above, they have been treated with a drug used for diabetes called metformin. Metformin increases insulin sensitivity. In addition to improving glucose tolerance, metformin treatment may allow women with PCOS to ovulate. Any woman not wanting to get pregnant who is taking metformin but not birth control pills needs another birth control method, such as a diaphragm.
Some doctors believe that metformin should be the main treatment for PCOS. It is especially important to treat women with evidence of the metabolic syndrome. There is some evidence that metformin treatment may actually prevent women from becoming diabetic.
All women are advised to lose weight and increase their exercise, which also counteracts some of the effects of the metabolic syndrome and PCOS.
What about women who are trying to get pregnant?
Sometimes weight loss and exercise along with metformin treatment will cause ovulation and make pregnancy possible. Most of the time, however, women will be treated with a medicine called clomiphene citrate, often along with metformin, to allow ovulation to occur. The treating doctor would most likely do blood tests to check if ovulation is occurring. Further treatment would depend on the person’s age and whether or not there is evidence of any other problem causing infertility.
A young, otherwise healthy woman with PCOS treated with clomiphene citrate, with or without metformin, may be able to ovulate and subsequently get pregnant. If there are other causes for infertility, they must also be treated.
What are some of the studies under way at present?
Studies are looking at whether or not PCOS is inherited. Others are evaluating various treatments for insulin resistance and the metabolic syndrome in PCOS patients, from medications similar to metformin to vitamins and food supplements. Different ways to treat the infertility are being studied, as is the natural history of the syndrome. Right now there are at least 150 clinical trials recruiting, in process, or completed and awaiting publication of results.
Anyone interested in participating in a clinical trial should go to http://clinicaltrials.gov/ct2/search and search for trials on PCOS.
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