PCOS is a very common hormone disorder in women, a leading cause of infertility, and one of the most underdiagnosed diseases in the United States. PCOS is characterized by a myriad of seemingly unrelated symptoms and may include irregular or absent periods, lack of ovulation, weight gain, acne, excessive facial hair and infertility. Even more serious, women with PCOS may be at higher risk for developing cardiovascular disease, Type 2 Diabetes, and endometrial cancer, especially if PCOS is left untreated.
Surprisingly, most women with PCOS don’t even know they have it. Less than 25 percent of women with PCOS have actually been diagnosed, largely because women and their health care providers tend to look at the wide variety of symptoms individually rather than collectively. Most women are never officially diagnosed until they begin struggling with infertility and seek help in getting pregnant.
Polycystic Ovary Syndrome: Causes, Diagnosis and Treatment
Polycystic ovary syndrome (PCOS) is a very common disorder that many women first learn about while seeking the cause of their infertility. PCOS affects 5-10% of women of reproductive age, making it one of the most common hormonal disorders in this age group. The exact cause of PCOS is not known. It is likely that a combination of factors leads to the development of PCOS. PCOS is thought to be a genetic trait and may run in families. Environmental factors such as the diet that one consumes are also thought to play a role in the development of PCOS.
Women with PCOS have three characteristic symptoms. Women are diagnosed with PCOS when they have at least two of these three symptoms:
- Irregular periods
- Excess androgens — either measured in the blood or seen through symptoms such as acne or excess hair growth
- Polycystic ovaries — seen on ultrasound
Women with PCOS may have irregular periods. They may have only 6 to 8 periods per year. They may get their period every month for a few months and then skip a month or two or they may go many months without having a period. Many women with PCOS will have infertility associated with their irregular menses. Also, when women with PCOS do become pregnant, they have an increased rate of miscarriage.
Another common symptom of PCOS is acne or oily skin. Acne may occur over the face but may also be found over the back or chest. This is due to relatively higher levels of testosterone circulating in the bloodstream. Testosterone is a hormone that is found in much higher levels in men. Women with PCOS do not have male levels of testosterone but the levels of testosterone may be higher than expected for females. These higher levels of circulating testosterone can also cause excess facial hair on the chin or upper lip or excess hair growth on the chest and abdomen. The hormone imbalances seen in PCOS can also cause a type of hair thinning which occurs at the front of the scalp. Sometimes blood tests can show excess levels of testosterone in women with PCOS but other times they do not.
The third common feature of PCOS is what is called polycystic ovaries. This can be seen on a transvaginal ultrasound. This is actually a misnomer as the ovaries of women are not really full of cysts but rather ovarian follicles that each contains an egg. All women have these follicles in their ovaries and each month a group of follicles start to develop, with one going on to be the dominant follicle that ovulates the egg. The ovaries of women with PCOS may contain many small follicles that do not go on to ovulate an egg each month. These follicles fail to develop normally because of the hormonal imbalances in PCOS. Because the ovaries do not grow and ovulate an egg each month, women with PCOS may also experience difficulty getting pregnant.
Obesity is also common in women with PCOS. Up to 50-60% of women with PCOS are obese. Symptoms of PCOS such as those described above can be worsened by obesity. The hormonal imbalances found in women with PCOS may cause them to be more likely to gain weight and become obese. Women with PCOS are also prone to developing insulin resistance in which the body produces excess amounts of insulin. This is thought to be a precursor to Type II diabetes. Women with PCOS are at greater risk of developing diabetes and therefore all women with PCOS should be screened for insulin resistance.
If you suspect that you might have PCOS, it is important to first get an accurate diagnosis. PCOS can only be diagnosed through assessing hormone levels in the blood, primarily LH (luteinizing hormone), FSH (follicle stimulating hormone), testosterone, DHEAS (dehydroepiandrosterone sulfate), and insulin.
It is also critical for your health care provider to evaluate your symptoms and medical history as he or she makes a diagnosis; therefore, you should be open and honest about all of your symptoms, even if you think they are unrelated. In addition, your health care provider might want to do an ultrasound to look at your ovaries.
There are treatments available for women with PCOS. These treatments do not cure the disease but rather help improve the symptoms of PCOS. For women with PCOS who are obese, diet and exercise to maintain a normal body weight may alleviate many of the symptoms of PCOS. In fact, for obese women, losing even 5-10% of body weight may help. Oral contraceptive pills are often given to correct some of the hormonal imbalances found in PCOS and can help decrease acne and excess hair growth as well as regulate menstrual cycles. Acne can also be treated with topical ointments or antibiotic creams. Women with excess hair growth often find laser electrolysis helpful. Metformin is an oral medication that may be prescribed to women with PCOS who are insulin resistant.
Women who are having difficulties conceiving may take a medication called clomiphene citrate or clomid to help them ovulate regularly. In women with PCOS who take clomid, about 80% will ovulate in response to the medication and 30-40% will become pregnant. About half of women will ovulate when taking one pill a day (50 mg) on cycle days five through nine. The other 50% of women do not ovulate on this dose of clomid and may need a higher dose or another medication. Using clomid increases your chances of having a multiple pregnancy to 8-13%, with twins being the most common. If pregnancy does not occur after six cycles of clomid use, further evaluation or a change in therapy is recommended.
If you think you may be experiencing any or all of the symptoms of PCOS, it is important to see a doctor for diagnosis and treatment.
Unveiling the PCOS Mystery
Polycystic ovary syndrome (PCOS) is a common cause of infertility among women. PCOS causes about 30 out of every 100 cases of female infertility. PCOS was first recorded in 1935, but its symptoms have been observed as far back as 460-377 B.C. The symptoms of PCOS include excessive hair growth and lack of menses. These symptoms can be embarrassing, but they also pose serious health risks. However, with proper treatment, the health outlook of PCOS can be controlled and managed.
What is PCOS?
Polycystic Ovary Syndrome is a condition whose exact cause is not known. PCOS is characterized by hormonal imbalance and women may have:
- Excessive hair growth
- Oily skin
- Darkened patches of skin
- Weight gain
- Abdominal pain
- Infrequent, abnormal or no menses (not related to birth control)
Someone having these symptoms would need further testing. First-degree relatives of women with PCOS are at greater risk of developing the syndrome. PCOS is diagnosed when an ultrasound detects multiple cysts in the ovaries.
How does hormonal imbalance cause a problem?
Menstruation/Fertility: In healthy females, normal changes in hormones occur, causing regular menstruation. A regular cycle is typically three to five days of menses with 21 to 35 days between cycles. With PCOS, hormones change irregularly. This can lead to skipped menses, lack of menses, and/or abnormal bleeding. In essence, with PCOS, an egg never leaves the ovary to possibly join with a sperm to make a baby.
Hair, oily skin, and acne: High insulin levels lead to excess testosterone. This causes unwanted hair growth, oily skin, and acne.
Obesity: When insulin levels are increased for long periods, cells become “resistant.” Over time, this insulin resistance may lead to obesity, type 2 Diabetes and heart disease. Women with PCOS should be aware of these risks. In most cases, weight increases before insulin resistance is detected. A lab test can reveal high blood sugar levels. This may be a first sign of insulin resistance.
What are the options for treatment?
Since the exact cause of PCOS is unknown, treatment focuses on correcting hormonal imbalances and insulin resistance. In overweight or obese women, weight loss is beneficial. This alone can restore hormone balance and fertility. Weight loss also decreases the risk for high cholesterol, high blood pressure, and diabetes.
Treatment for PCOS is tailored to address a woman’s reproductive concerns. For women in whom pregnancy is not desired, oral contraceptives may be prescribed. When pregnancy is desired, ovulation induction agents such as Clomiphene Citrate, Letrozol, or gonadotropins may be used. Adjunctive treatments such as Metformin have been used to decrease insulin resistance. Surgical management for patients with refractory PCOS is an option but may be associated with adhesion formation and subsequent infertility.
Complementary treatments and natural medicine offer a variety of tools. Nutritional counseling and weight reduction may improve insulin resistance and improve a patients overall likelihood of spontaneous ovulation and/or response to ovulation induction treatments. Acupuncture and vitamin supplements, such as myo-inositol, are treatment options for PCOS. Psychological support may be necessary for some women with PCOS.
In many cases, PCOS can be successfully managed and fertility achieved. A plan of care should be tailored to address your specific needs and goals. Consider following a multidisciplinary approach to management that incorporates medical, nutritional, and psychological support to enhance the likelihood of success in achieving the best result in management of PCOS. This allows for success of achieving your health goals.
- Tori Hudson, N.D. (2008) Women’s Encyclopedia of Natural Medicine: McGraw-Hill
- Leon Speroff, Robert H. Glass, Nathan G. Kase (1999) Clinical Gynecologic Endocrinology and Infertility, 6th edition Lippincott, Williams & Wilkins
- Kathryn A Martin, MD, Ricardo Azziz, MD, William F Crowley, Jr, MD Epidemiology and pathogenesis of the polycystic ovary syndrome in adults
- Ricardo Azziz, MD, Daniel A. Dumesic, MD, Mark O Goodarzi, MD Polycystic Ovarian syndrome; An ancient disorder?
Content contributions by: Dr. Jennifer Kulp Makarov and Dr. Roselynd R. Bryant.