What is Polycystic Ovary Syndrome (PCOS)?

What is Polycystic Ovary Syndrome (PCOS)?

Polycystic ovary syndrome (PCOS), also known as Polycystic ovarian syndrome or Stein-Leventhal Syndrome, is a condition that affects a woman's ovaries. It is characterized by polycystic ovaries (cysts develop in the ovaries), irregular or no menstrual periods, irregular ovulation and high levels of androgens in the body. Androgens are male hormones. Women with PCOS usually have problems getting pregnant.

According to the Office on Women's Health, USA, polycystic ovary syndrome affects about 1 woman in every 10. It can even affect girls as young as 11 years of age.

The National Health Service, UK, estimates that 1 in every 5 women has polycystic ovaries, but most of them have no symptoms.

The PCOS Foundation refers to PCOS as the "Silent Killer" because it cannot be diagnosed with one simple test and many women are undiagnosed. Signs and symptoms vary from patient to patient.

PCOS has been associated with a higher risk of developing type 2 diabetes, insulin resistance, hypertension (high blood pressure), heart disease and high cholesterol. That is why early diagnosis is so important - the earlier it is treated, the better the outcome for the patient.

In PCOS, the ovaries produce excess male sex hormones. Small cysts form on the ovaries, which do not produce enough of a hormone that triggers ovulation. The ovarian follicles, which have filled with fluid in preparation for ovulation, remain as cysts when ovulation does not occur.

What are the signs and symptoms of polycystic ovary syndrome?

A symptom is something only the patient feels and describes, such as pain, while a sign is something others can identify, such as a lump or rash.

Signs and symptoms tend to emerge during late adolescence or early adulthood.

Some women do not have all the symptoms, and each one can range from mild to severe. In many cases, all the woman complains of is the inability to get pregnant or menstrual problems.

The most common signs and symptoms of PCOS are:

Irregular or no menstrual periods

Problems getting pregnant - this could be because there is no ovulation, or it is irregular

Hirsutism - excessive hair growth, usually on the buttocks, back, chest or face

Hair loss (from the head)

Acne

Pelvic pain

Patches of dark skin at the back of the neck, possibly some other areas of the body. This is caused by too much insulin.

Infertility

Polycystic ovary syndrome is a common cause of infertility among women. In fact, a large proportion of women do not know they have PCOS until they go and see their doctor because they are having problems getting pregnant.

A fertile woman should ovulate once during each menstrual cycle - an ovum (egg) should be released into the uterus. Women with PCOS either ovulate irregularly or not at all.

Polycystic ovaries

Polycystic ovaries are when the ovaries have a collection of little cysts that look like beads around their edge. The cysts do not cause any real problem, but they could be a sign of something else that is wrong.

Usually, when a woman ovulates during each menstrual cycle, a number of eggs develop in each ovary and eventually one, the "dominant" egg, is released during ovulation. The other eggs shrivel back down into the ovary. In PCOS, the bead-like cysts around the ovary are the remains of dominant eggs that were never released.

Although this may sound unlikely, polycystic ovaries alone do not necessarily mean the woman has PCOS. For a PCOS diagnosis the woman needs to have abnormal menstrual cycles and some sign(s) of androgen excess (acne, excessive hair, etc).

Some women with PCOS have "normal" ovaries with no apparent cysts, while others with polycystic ovaries may not have PCOS.

In January, 2013, the National Institutes of Health convened an independent panel to determine whether polycystic ovary syndrome is the right name for the common hormone disorder. The experts concluded that the current name, which focuses on a criterion - ovarian cysts - causes confusion and is a barrier to research progress and effective patient care.

Dr. Robert A. Rizza, panel member and professor of medicine at the Mayo Clinic in Rochester, Minnesota, said "The name PCOS is a distraction that impedes progress. It is time to assign a name that reflects the complex interactions that characterize the syndrome. The right name will enhance recognition of this issue and assist in expanding research support."

Researchers from Monash University in Australia found that new mothers with PCOS were more likely to be overweight and less likely to breastfeed.

What are the causes of polycystic ovary syndrome?

Experts are not sure what the causes of PCOS are. Most agree that hormone levels probably play a key role.

Insulin resistance - insulin resistance leads to higher levels of blood insulin, which in turn makes the ovaries produce too much testosterone hormone (androgens). This undermines the development of sacs in the ovaries where eggs develop (follicles), leading to abnormal or non-existent ovulation.

Insulin resistance can also make people put on weight, which makes PCOS symptoms worse.

Hormonal imbalance - an imbalance in certain hormones is common in women with PCOS, including:

High testosterone - although females produce small amounts of testosterone, it is a "male" hormone.

High luteinizing hormone (LH) - LH stimulates ovulation, but if levels are excessively high, the proper functioning of the ovaries may be disrupted.

Low SHBG (sex hormone binding globulin) levels - SHBG helps reduce the effects of testosterone.

High prolactin levels - prolactin stimulates the production of milk in the breast glands in pregnancy. High prolactin is present only in some patients with PCOS.

Nobody is sure why these hormonal problems emerge. Some say that the problem could originate in the ovary itself, part of the brain that controls hormonal production, or in other glands in the body. It is also possible that insulin resistance triggered these changes.

Genes - a woman is more likely to develop polycystic ovary syndrome if her mother, aunt or sister also has/had it.

Scientists at the Medical College of Georgia at Georgia Regents University reported in the journal Diabetes that high activity levels of a microRNA called miR-93 in fat cells hinders insulin's use of glucose, contributing to PCOS and also insulin resistance.

Scientists from the University of Oxford and Imperial College London found that a gene implicated in the development of obesity is also linked to susceptibility to PCOS.

Bisphenol A (BPA) - researchers at the University of Athens Medical School in Greece found higher BPA levels in women with PCOS compared to other women of the same age. They also found a significant positive association between male sex hormones and BPS in women with PCOS. This suggests that BPA probably has a role in ovarian dysfunction.

BPA is a common industrial compound used in dental materials, plastic consumer products, and food and drink packaging. Study leader, Evanthia Diamanti-Kandarakis, MD, PhD, said "These women should be alert to the potential risks and take care of themselves by avoiding excessive every-day consumption of food or drink from plastic containers."

Exposure to androgens in the womb - according to a study published in Human Reproduction Update in 2005, excessive exposure to androgens (male hormones) while in the womb may have a permanent effect on gene expression, making some genes not work in the way they are supposed to, leading to PCOS later on, as well as insulin resistance.

Diagnosing polycystic ovary syndrome

If you have some of the typical hallmark symptoms of PCOS you should see your doctor as soon as possible. You will be asked about your medical history, symptoms, menstrual periods, and weight changes.

The doctor will also carry out a physical exam, which will include checking your blood pressure.

Pelvic examination - the doctor will visually and manually check your reproductive organs.

The following diagnostic tests may be recommended:

Ultrasound scan - to determine whether you have polycystic ovaries.

Blood test - to determine hormone and cholesterol levels, and screen for diabetes.

According to the National Health Service, UK, for a diagnosis of PCOS to be made, other causes of the same symptoms need to be ruled out and the patient must meet at least two of the following criteria:

The patient has infrequent or irregular menstrual periods

According to blood tests, the patient has high levels of androgens, such as testosterone. In some cases, just the signs of excess androgen

Scans show the patient has polycystic ovaries.

What are the treatment options for polycystic ovary syndrome?

Polycystic ovary syndrome is incurable. However, there are several ways it can be treated. Treatment options depend on the symptoms, and may include:

Losing weight - obese or overweight women with PCOS who lose weight and adopt a healthy lifestyle can significantly reduce their risk of long-term health problems.

If you lose weight your insulin levels also drop, resulting in lower testosterone levels. Lower testosterone is a better environment for ovulation. Lower testosterone improves fertility, reduces excessive hair growth and acne.

The contraceptive pill - if you are not trying to get pregnant and are aiming for regular periods. This treatment will also reduce your long-term risk of developing endometrial cancer if you have no periods.

An article published in CMAJ (Canadian Medical Association Journal) reported that women with PCOS on combined oral contraceptives have double the risk of blood clots compared to women without PCOS taking the same combination.

Anti-male hormone medications - these reduce the masculine effects of testosterone, such as loss of hair from the head, and excess facial hair.

Clomifene - this medication fixes your hormone imbalance, increasing the likelihood that you ovulate, which in turn improves your fertility.

Gonadotrophins - may be recommended by your doctor if you have not responded to clomifene. There is a risk of multiple pregnancies (twins, triplets), because gonadotrophins might overstimulate the ovary.

Metformin (Glucophage) - a medication used for treating diabetes can increase ovulation in patients with PCOS. Metformin may also minimize the health problems caused by insulin resistance, as well as regulating excessively high levels of male hormones. Metformin can be taken together with clomifene.

Swedish researchers found that metformin in combination with liraglutide led to more weight loss than administering either drug alone.

Eflornithine - a cream that is applied to the skin to slow down the growth of facial hair. Eflornithine does not remove hair. Electrolysis or laser hair removal are permanent hair removal options.

Surgery - laparoscopic ovarian drilling (LOD) involves surgically treating the ovaries using laser or heat. This procedure destroys the tissue that produces androgens.

LOD corrects the hormone imbalance in women with PCOS, thus restoring normal function of the ovaries. LOD lowers levels of luteinising hormone and testosterone and raises levels of follicle-stimulating hormone.

Doctors may recommend surgery if the patient has not responded to clomifene.

What are the complications of polycystic ovary syndrome?

Women with PCOS have a higher risk of developing the following conditions or diseases, especially if they are obese/overweight:

Abnormal bleeding from the uterus

Blood cholesterol and lipid abnormalities

Endometrial cancer - cancer of the lining of the uterus

Gestational diabetes - diabetes during pregnancy

High levels of C-reactive protein, a disease marker for cardiovascular diseases

Hypertension (high blood pressure)

Metabolic syndrome

Pregnancy induced hypertension

Severe liver inflammation (nonalcoholic steatohepatitis)

Sleep apnea - women with PCOS who also have obstructive sleep apnea have a much higher risk of pre-diabetes, researchers from the University of Chicago Center for PCOS reported

Type 2 diabetes

Researchers from the Karolinska Institute, Sweden, reported in the BMJ (British Medical Journal) in October, 2011, that women with polycystic ovary syndrome have a higher risk of complications during pregnancy, including diabetes, pre-eclampsia and giving birth prematurely.

Video - Dr. Ruman discusses PCOS

Dr. Jane Ruman, Infertility Specialist at RMA of New York, discusses polycystic ovarian syndrome, its causes, symptoms, treatment options and getting pregnant with PCOS.

Written by Christian Nordqvist

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