PCOS

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome is a hormone imbalance that interferes with normal ovulation. Women with PCOS do not have normal, regular menstrual cycles. This hormonal imbalance also affects other body systems, such as the metabolic and cardiovascular systems.

Most women with PCOS will have numerous (“poly”) small cysts (“cystic”) on their ovaries at some time (pearl necklace appearance on sonogram). However, some women with PCOS do not have polycystic ovaries but have other symptoms of the syndrome.

What causes PCOS?

The cause of PCOS is not fully understood, but genetics play a factor. You have an increased risk of PCOS if you have a family history of PCOS, diabetes, heart disease, high blood pressure, and high cholesterol. If you have the syndrome, your sisters and daughters have a 50% chance of developing PCOS. There has been several studies that associate high carbohydrate diet with an increased incidence of PCOS.

What are the symptoms of PCOS?

Because there is such a wide range of symptoms, PCOS is defined as a syndrome, not a disease. The most common symptoms of PCOS are irregular menstrual cycles; acne; weight problems, such as weight gain or upper body obesity; and abnormal hair growth. Many women also experience infertility or pregnancy loss. The ovaries often become enlarged and may contain one or more abnormal cysts. Enlarged ovaries are easily detected by a transvaginal ultrasound.

Many symptoms of PCOS occur either early in the condition or develop gradually. Women with PCOS, especially overweight women, may have insulin resistance and have an increased risk for diabetes and high lipids.

How is PCOS diagnosed?

There is no single test to diagnose PCOS. It is diagnosed in women who have irregular menstrual cycles when blood tests or physical symptoms suggest they may have elevated levels of male hormones, hirsutism, or the typical PCOS pattern noted on ultrasound. Many women are diagnosed with PCOS after being evaluated for miscarriages and infertility. The ASRM-ESHRE criteria to diagnose PCOS includes having 2 of these 3 findings:

1. High androgen levels

2. Irregular cycles

3. Polycystic appearing ovaries on ultrasound

How is PCOS treated?

PCOS may increase your risk of developing other conditions or diseases over time, such as diabetes, high cholesterol, heart disease, and endometrial hyperplasia. Treatment involves weight loss, diet change, and increasingly, medications called Insulin sensitizers (such as Glucophage [Metformin], Actos, Actoplusmet, Avandia, Avandiamet).

Symptoms

Many symptoms of polycystic ovary syndrome (PCOS) start gradually and, at first, may be thought to be related to some other medical problem. You may have only a few symptoms or many symptoms.

Symptoms of PCOS include:

• Fewer than eight menstrual cycles in a year, more than 35 days between cycles, or no menstrual periods. Failure to ovulate each month occurs in almost 50% of women with PCOS.
• Abnormal vaginal bleeding. This symptom occurs in about 30% of women with PCOS.
• Excess hair growth (hirsutism) on the face, chest, back, stomach, thumbs, or toes. More than 70% of women with PCOS complain of excess hair growth.
• Skin problems, such as acne, oily skin, dandruff, dark skin patches (acanthosis nigricans) on the neck, groin, underarms, or in skin folds, or skin tags (acrochordons) in the armpits or neck area.
• Depression or mood swings. Many women have emotional problems related to the many physical symptoms of PCOS, such as excess hair, obesity, or infertility.
• Weight gain or upper body obesity (more abdominal fat than hip fat). This is also known as android obesity and is related to increased male hormone (testosterone) levels.
• Infertility.
• Symptoms of insulin resistance, which increases the risk of developing diabetes in women with PCOS. You may also develop diabetes at a younger age because of PCOS. About 30% of women with PCOS have impaired glucose functioning, and 7% to 10% have type 2 diabetes. Some symptoms associated with insulin resistance include skin changes, such as skin tags or dark skin patches (acanthosis nigricans) and upper body weight gain.
• High blood pressure (hypertension).
• Male pattern baldness or thinning hair (alopecia).

Most women with PCOS seek medical evaluation for a specific symptom, not knowing that they have PCOS. The most common reasons women seek evaluation are:

• Menstrual problems.
• Excess hair growth (hirsutism).
• Infertility.
• Weight gain or upper body obesity.

Conditions with symptoms similar to PCOS

Conditions that cause symptoms similar to PCOS include:

• High prolactin hormone levels.
• Excess adrenal hormones. This excess level may be present from birth (congenital adrenal hyperplasia) or may occur in adulthood, causing irregular menstrual cycles and excess hair growth (hirsutism).
• Cushing's syndrome.
• Tumors of the ovary or adrenal gland that produce male hormones.
• Thyroid problems, such as autoimmune thyroiditis, hypothyroidism, or hyperthyroidism.
• Eating disorders.

You may have more regular menstrual cycles as you near menopause. The reason for this is not known. However, your history of PCOS may still increase your long-term risk of high blood pressure (hypertension), heart disease, diabetes, or endometrial cancer.

Exams and Tests

If you are not pregnant or breast-feeding and have had fewer than 8 menstrual cycles in the past year, an evaluation for polycystic ovary syndrome (PCOS) or other hormonal problems is needed. PCOS has such a wide range of symptoms that no single test can be used to diagnose it.

Your physician will ask about your medical history and will perform a physical examination. The medical history includes questions about your menstrual cycles and your lifestyle, including what you eat, changes in your weight, how you exercise, as well as questions about any family history of endocrine problems. The physical examination include a pelvic exam and a vaginal ultrasound.

Additional blood tests might also be done to determine whether other conditions that have symptoms similar to PCOS (as noted above) might be present.

Treatment Overview

Weight problems or metabolic problems that may develop with polycystic ovary syndrome (PCOS) are usually treated with medications and lifestyle considerations. However, since PCOS causes many different symptoms and problems, treatment varies from woman to woman.

The treatment you and your health professional select will focus on:

• Managing your specific symptoms, such as irregular menstrual cycles, excess hair growth (hirsutism), or infertility.
• Preventing long-term complications, such as weight gain, diabetes, or high blood pressure (hypertension).
• Possibly changing your diet to a low carbohydrate-high protein diet
• Reducing your risk for developing other medical conditions, such as heart disease, high cholesterol, or endometrial hyperplasia.

Since PCOS is a lifelong condition, your treatment may change as you age. Most women with PCOS can lead healthy lives with medical treatment and lifestyle changes.

What can you do

You can help yourself managing the symptoms of polycystic ovary syndrome (PCOS) and living a healthier life. Measures such as controlling your weight can help reduce your risk for diabetes, high blood pressure (hypertension), and high cholesterol.

Weight control or weight loss is very important since it can restore normal ovulation cycles and fertility. Weight loss of as little at 5% to 7% over 6 months can reduce male hormone levels and restore ovulation and fertility in more than 75% of women with PCOS.

• Maintain a healthy body weight. A healthy weight is one at which you feel good about yourself, have energy for work and play, and can manage your PCOS symptoms.
• Lose weight. Reaching a healthy weight improves your health and prevents long-term complications. Your age, metabolism, genetics, and how much you exercise play an important role in how you gain and lose weight. It's important that you determine what you alone need to maintain a healthy weight and that you not compare yourself to others.
• Exercise. Make physical activity a regular and essential part of your day. There are many ways to get exercise; walking is one of the best. Choose fitness activities that are right for you to help boost your motivation. Think about your exercise preferences and try to identify some activities you enjoy.
• Eat a balanced diet. A balanced, healthy diet that includes specific fruits, vegetables, whole grains, and low-fat dairy products supplies your body's nutritional needs, satisfies your hunger, decreases your cravings, and lowers your risk for other medical conditions, such as cancer and osteoporosis. Many PCOS patients require a low carb diet (such as the South Beach Diet). In addition, you will generally feel better and have more energy if you eat a healthy diet.

Medications

Medication treatment for polycystic ovary syndrome (PCOS) focuses on regulating ovulation or treating your insulin resistance or both. Medication treatment for PCOS depends on your symptoms especially if you want to become pregnant. Medication may be prescribed to treat symptoms such as excess hair growth or acne.

Medications to treat reproductive or metabolic problems of PCOS may include:

• Combination estrogen and progestin hormones, such as birth control pills, vaginal ring, or skin patch. Estrogen may also help reduce your male hormone levels, which would then reduce your acne problems and excess hair growth.
• Clomiphene citrate (Clomid, Serophene) (fertility medications) and gonadotropin injections (LH and FSH).
• Insulin sensitizers such as Metformin (Glucophage), Actoplusmet, and Actos. These medications can reduce metabolic problems and male hormone levels in PCOS and thus help restore regular menstrual cycles. The effectiveness of these medication may be increased by any weight loss that occurs at the same time.
• Medications to suppress male hormones (antiandrogens), such as spironolactone (Aldactone).
• Synthetic progestin, such as medroxyprogesterone acetate, norethindrone, or progesterone.

Medications to treat excess hair growth (hirsutism), such as spironolactone (Aldactone), may be recommended. This would be an unlabeled use of spironolactone.

Some medications to treat hirsutism may increase your risk for metabolic problems, so it is important to discuss medication side effects with your health professional.

Vaniqa is a skin cream (topical) that reduces hair growth. It is helpful for many women with PCOS, but hair growth returns if the medication is stopped.

Treatment for acne may include nonprescription or prescription skin (topical) or oral medications. Some women notice an improvement in their acne after using combination hormone pills.

Surgery

• Laparoscopic ovarian drilling is a surgical treatment that can trigger ovulation in women with polycystic ovary syndrome (PCOS) who have not responded to weight loss and fertility medication is now rarely, if ever, indicated. Electrocautery or a laser is used to destroy portions of the ovaries. This surgery is rarely indicated currently because of the effectiveness of medical treatment, and the potential scar tissue formation.

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