Although polycystic ovary syndrome (PCOS) is one of the leading causes of infertility, it may not be well understood.
In an effort to shine a brighter light on this condition today, PCOS Advocacy Day, RMANJ Dr. Leo Doherty is lifting the fog on PCOS.
What is Polycystic Ovary Syndrome (PCOS)?
Polycystic ovary syndrome is a hormonal imbalance disorder that affects up to 20 percent of reproductive age women. Because the condition affects the body’s hormonal processes, it has an effect on ovulation and fertility. Many women with PCOS will have trouble conceiving naturally, but with the right treatment, chances of pregnancy are good.
Reproductive hormones are abnormally regulated in women with PCOS. The usual interplay between hormones that results in maturation of eggs and ovulation is abnormal, causing infertility (due to irregular/absent ovulation) and irregular periods. Androgen levels (Testosterone) are elevated, which can cause symptoms such as acne and unwanted hair growth on the face and other parts of the body.
Lack of ovulation over time can lead to abnormalities in the uterus where the endometrial tissue can become thickened, leading to heavy or irregular periods, and in extreme cases, endometrial cancer. Many women with PCOS also demonstrate insulin resistance, which makes them prone to weight gain and diabetes.
The number of eggs within a woman’s ovaries is finite, and gradually reduces over time. From puberty to menopause, women will go through hundreds of thousands of eggs, but only a small percentage of these eggs ever ovulate. In a perfect world, the hypothalamus, pituitary gland and ovaries all work together each month to grow follicles and release an egg.
OK, let’s break that down…
A runner’s analogy, if you will:
- Each month a number of eggs are present in follicles and are able to be stimulated for maturation and ovulation. We’ll call these follicles runners.
- In a normal menstrual cycle, the hypothalamus, pituitary and ovary interact together to stimulate one follicle (and the egg inside it) to grow and mature.
- That follicle (runner) will make it to ovulation (the finish line). The runners that didn’t get stimulated are degraded in a process known as atresia.
- Next month, there is a whole new group of runners, and these monthly “races” will continue until menopause.
- In women with PCOS, there are many more runners than usual in the monthly race for ovulation, but they never reach the finish line (ovulate), so there is no winner.
- In other words, there are a lot of follicles, but they are not maturing properly and not releasing an egg. As women get older, the number of runners decreases, and so do her chances of pregnancy.
Why do some women get PCOS and others don’t?
We know genetics play a large role in who develops PCOS – first degree relatives of women with PCOS (mothers and sisters) have up to a 30-50 percent chance of developing the condition.
There are also others theories about the cause of PCOS, such as the effect of the in utero environment on the risk of developing PCOS later in life. In utero exposure to elevated levels of testosterone, fetal undernutrition, and elevated AMH levels have been implicated in the development of PCOS.
What are the symptoms of PCOS?
The most common symptoms of PCOS are:
- Irregular periods or a loss of menstruation entirely
- Acne and abnormal hair growth (commonly on the face, chest, or abdomen) are commonly seen due to elevated androgen levels
- Obesity, difficulty losing or maintaining weight, and type 2 diabetes are also common
- Infertility can be a presenting symptom in couples trying to conceive
- Anxiety, depression and eating disorders are also seen in patients with PCOS
How is PCOS diagnosed?
Because irregular cycles are a common symptom of PCOS, a doctor taking a detailed history will ask about that woman’s menstrual cycle history and whether she has any other symptoms like acne, hair growth or difficulty losing weight.
On physical exam, the woman’s vital signs including height, weight and a calculation of Body Mass Index (BMI) are important. A thorough examination looking for signs of elevated testosterone or insulin resistance and to help rule out other conditions that may mimic PCOS is also important.
A transvaginal ultrasound will help doctors see whether the patient has ovarian features of PCOS (which should really be called polyfollicular ovarian syndrome since these women have many follicles and not cysts).
Then, the doctor will take blood tests to examine her levels of FSH, LH, estrogen, testosterone, AMH and to screen for insulin resistance. If indicated, an endometrial biopsy – where a sample of a woman’s endometrial tissue is examined – can screen for endometrial hyperplasia or cancer in women who have had prolonged amenorrhea (lack of a period).
How is PCOS treated in women who want to conceive?
The first line of treatment for women with PCOS is lifestyle modification. Modest weight loss and increase in lean muscle mass can have huge impacts on the abnormal hormone regulation seen in women with PCOS. For many women trying to conceive, medications are needed. The goal of treatment is to correct ovulation.
A woman may be prescribed Clomid, an ovulation inducing medication that indirectly promotes the production of FSH and the growth and release of a mature egg. Another medication commonly used to induce ovulation in women with PCOS is Letrozole.
After ovulation is induced with Clomid or Letrozole, the doctor may recommend timed intercourse or intrauterine insemination (IUI). Injectable FSH with IUI can also be used in women with PCOS, but has a higher risk of multiple pregnancy and must be done carefully and with close supervision.
In vitro fertilization (IVF) is another excellent treatment for women with PCOS and has superior success rates and a far lower chance of multiple pregnancy. For women not trying to conceive, the first treatment is behavioral change such as weight loss, healthy eating and exercise. Birth control pills and insulin-sensitizing medication (Metformin) can also be given to improve irregular periods.
Is there a cure?
No, but with the treatments outlined above, and ongoing research into the condition, there is reason to be hopeful about pregnancy with PCOS. That said, once women are done childbearing, they should not ignore their PCOS, as it does predispose them to increased risk of diabetes and other metabolic conditions.