Polycystic Ovary Syndrome
Polycystic ovarian syndrome (PCOS), also called Stein-Leventhal Syndrome, is the most common endocrinologic disorder in women of reproductive age. Approximately 5-10% of reproductive age women have PCOS. This syndrome can have many symptoms. However, the two key components defining this disorder must include chronic anovulation (inability to ovulate an egg) and clinical hyperandrogenism (elevated male-type hormones). The reason for multiple-cyst development is not clear but appears to be related to intrinsic insulin resistance demonstrated in women with PCOS. In comparison to normal ovulation, women with PCOS are not able to completely develop a fully mature egg on their own, and therefore the ovulatory process in not completed.
PCOS is comprised of several clinical features, each of which may be present to a greater or lesser degree. The various symptoms of PCOS can be irregular or absent menstrual cycles, infrequent or absent ovulation, excess facial and body hair, male-pattern balding, acne of face/back/chest and infertility. The pattern and location of hair growth is important; this is a sign of insulin resistance. Other findings can include an elevated FSH to LH hormone ratio, elevated levels of male hormones, multiple small cysts on the ovaries and elevated cholesterol. Some women have been found to have polycystic ovaries without associated abnormalities of menstruation, hair growth or fertility.
When hormones are elevated in the male level then hair growth occurs in androgen-dependent fashion. Typically women do not have hair on their face or on their lower abdomen unless their male hormones are elevated. When this occurs, hair growth does occur in a similar fashion as it does in men and is very suggestive of PCOS.
Importance of Seeing a Specialist
Because PCOS encompasses such a broad spectrum of signs and symptoms, diagnosis can be frustratingly difficult. As there is not one specific sign or symptom that points directly to PCOS, it is important to see a specialist who can diagnose this disorder and prescribe treatment. In 2003, an international consensus expanded the definition of PCOS to include women who demonstrate two of the three following conditions:
- irregular or absent ovulation
- elevated levels of androgenic (male) hormones
- polycystic ovaries on ultrasound
Many, but not all, women with PCOS have enlarged ovaries with many small cysts (fluid-filled sacs) that are visible on ultrasound, a finding that can also be seen in approximately 20% of women with normal menstrual cycles.
Lack of Ovulation
The lack of ovulation in women with PCOS results in a continuous exposure of the lining of the uterus or endometrium to estrogen. This causes excessive thickening of the endometrium and may cause heavy, irregular bleeding. Over years, endometrial cancer may result due to this continuous stimulation.
Metabolic Features Including Insulin Resistance
The causes of PCOS are unknown. Driving the abnormal levels of ovarian hormones in PCOS women is an elevation of the hormone insulin. Additionally, this imbalance contributes to an excess of male hormone production by the ovaries, which can be worsened by insulin resistance. There is no cure for PCOS, though the various symptoms can be addressed and managed, and therefore help reduce the risk of long-term health consequences.
Specific Goals of Treatment
If you are diagnosed with PCOS, treatment will depend upon your goals. Dealing with PCOS can be emotionally difficult. Women with PCOS may feel self-conscious about their excessive hair growth or weight, as well as their inability to have children. If fertility is the primary concern, then ovulation is induced through orally administered medications.
Ruling Out Other Factors
Prior to starting treatment, it is recommended that other factors, which may be responsible for irregular cycles, be evaluated. This includes ruling out a thyroid disorder or elevated prolactin which may cause irregular menstrual cycles. In cases where ovulation is irregular or absent, drugs such as Clomid (Clomiphene Citrate) can be used, as well as insulin-sensitizing drugs such as Metformin.
If fertility is not an immediate concern, hormonal therapies often correct the problems associated with PCOS. Medications commonly used include birth control pills, which may reduce the hirsutism (excessive hair growth) and regulate menstrual cycles, and are often combined with other medications such as spironolactone and Vaniqa cream to reduce body and facial hair.
For overweight women, simply losing 10-15% of total weight may be enough to allow spontaneous ovulation to occur. Weight loss is associated with lowered androgen effects, less insulin resistance, an improved lipid profile and resumption of ovulatory function. We understand that it is easy to tell someone to lose weight, but can be very difficult to actually lose weight. Exercise is also an important component of treatment and has been shown to resume ovulation and increase chances for pregnancy.
Studies with Metformin indicate that most women with PCOS will spontaneously ovulate after 3 months of treatment, or if not ovulatory, will become Clomid “sensitive”. One must be carefully screened prior to a course of Metformin and must be monitored during treatment. Side effects are mostly gastrointestinal (nausea, vomiting, diarrhea). We frequently start Metformin at a dose of 500 mg per day for one week working up to a total dose of 2000 mg per day. If gastrointestinal side effects develop, we can try using a long-acting form of Metformin which has a lower incidence of these side effects.
If fertility medications are required, the first and simplest step is to use Femara (letrozole) or Clomid (clomiphene citrate). We usually start patients at 5 mg of femara and increase the dosage of the medication based on individual response. Ovulation is documented with a progesterone level obtained in the luteal phase of the cycle to confirm ovulation. If ovulation is not achieved with a dose of 7.5 mg of femara or 150 mg/day of clomid, then other strategies have to be investigated. If Clomid fails to successfully induce ovulation, a group of injectable medications, known as gonadotropins may be used. Gonadotropins are administered to stimulate the growth of one or two eggs, being careful not to stimulate the growth of too many eggs. Follicular growth and development is carefully monitored by hormone measurements and ultrasound examinations. If monitoring shows that too many follicles are developing, and the risk of multiple pregnancy is high, then the treatment will be canceled.
Reducing Risk of Multiples
In vitro fertilization (IVF) is the most successful treatment for women with PCOS. This treatment is used to reduce the risk of multiple gestations that can occur with gonadotropins and intrauterine insemination (IUI). IVF is also used when pregnancy has not occurred with other treatment.
PCOS is comprised of several symptoms, each of which may be present to a greater or lesser degree:
- irregular or absent menstrual cycles
- infrequent or absent ovulation
- excess facial and body hair
- male-pattern balding
- acne of face/back/chest
- elevated FSH to LH hormone ratio
- elevated levels of male hormones
- multiple small cysts on the ovaries
- elevated cholesterol
- discoloration of the skin