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PCOS


Polycystic Ovary Syndrome (PCOS) is a condition I see frequently in my practice. It is thought to be one of the most common endocrine (hormone) disorders in women, affecting between 5 and 10% of women.


Polycystic Ovary Syndrome (PCOS)is a condition that causes irregular menstrual periods because ovulation is not occurring and levels of male hormones in women are elevated. PCOS is a collection of problems that are found together and not all women with PCOS have all the same symptoms. To be diagnosed with PCOS, a woman must have 2 of 3 possible issues: chronic lack of ovulation (anovulation), chronic high testosterone (hormone) levels (hyperandrogenism) and ovaries that have multiple fluid-filled sacs (polycystic). The most common symptoms of PCOS include absent or irregular menstrual periods, excessive facial hair growth, acne and/or male-pattern scalp hair thinning and infertility.


The causeof PCOS is not completely understood but involves complex genetic traits that are influenced by environmental factors. A susceptible person likely inherits variants in genes that regulate the action of hormones and insulin, the development of ovarian follicles (eggs), and weight and energy regulation. At the level of the reproductive system, it is believed that abnormal levels of the pituitary hormone luteinizing hormone (LH) and high levels of male hormones (androgens) interfere with normal function of the ovaries.


An irregular or absent menstrual cycle is a hallmark of PCOS. In women with PCOS, multiple small follicles (small fluid filled sacs containing immature eggs) accumulate on the ovaries, hence the term polycystic ovaries. None of these small follicles are capable of growing to a size that would trigger ovulation. As a result, levels of estrogen, progesterone, luteinizing hormone and follicle stimulating hormone become imbalanced.


Metabolic abnormalities are at the heart of PCOS. The metabolic system controls the processing of carbohydrates, fats and proteins. Insulin is an important metabolic hormone that regulates blood glucose levels. When blood glucose levels rise, for example after eating, specialized cells in the pancreas produce insulin to help the body use glucose for energy. Women with PCOS often have a condition called insulin resistance in which increased levels of insulin are required to maintain normal glucose levels. Over time, blood glucose levels can continue to rise despite increased insulin levels and the person is said to have type 2 diabetes. This can occur in both normal-weight and overweight women with PCOS.


There are several other health risks associated with PCOS. Many, but not all, women with PCOS are overweight or obese and at higher than average risk of developing obstructive sleep apnea. The metabolic changes associated with PCOS also encourage extra weight around the middle, high cholesterol and high blood pressure. When ovulation doesn’t happen, it interrupts the normal hormone cycle and causes the lining of the uterus to be exposed to constant levels of estrogen. This can contribute to the lining of the uterus becoming too thick and cause abnormal uterine bleeding and/or lead to uterine cancer or pre-cancerous changes. Lack of ovulation can also make it difficult to get pregnant. Finally, women with PCOS are at increased risk of both depression and anxiety.


Treatments for PCOS are aimed at alleviating symptoms and reducing risk for/correcting the health risks described above. Hormonal birth control (oral contraceptives, patch, vaginal ring) can be used to regulate menstrual periods and protect from uterine cancer; they also have benefit of treating acne and facial hair. An IUD or implant containing progesterone can reduce bleeding and protect against uterine cancer but does not have the benefit of treating acne or facial hair. Anti-androgen medications (such as spironolactone) can be used to help with acne and facial hair as well. Weight loss is one of the most effective ways to manage insulin abnormalities, irregular menstrual periods and other symptoms of PCOS. Metformin is a medication that improves the effectiveness of insulin produced by the body and is recommended for women with PCOS in some circumstances.


Treating infertility in women with PCOS involves restoring regular ovulation. The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest weight loss may allow a woman to begin ovulating normally; in addition, weight loss can improve the effectiveness of other fertility treatments. Clomiphene citrate is an FDA-approved oral medication that stimulates the ovaries to release one or more eggs. Letrozole is a medication that is FDA-approved for the treatment of breast cancer but not for ovulation induction; however, many experts now recommend letrozole as the first choice of treatment for women with PCOS who want to conceive. Sometimes, injectable medications (gonadotropins) are needed if ovulation does not occur with oral medications. The use of any ovulation induction medication increases the risk for multiple gestations, however injectable medication to a much greater degree. Anyone using oral or injectable ovulation induction/ovarian stimulation medications requires close monitoring to prevent overstimulation. The trick with PCOS is to stimulate the ovaries enough for ovulation to occur but not enough to create a reality TV show. Fun fact: IVF is the best way to avoid a multiple pregnancy as fertilization occurs outside the body and then a single embryo can be placed back in the uterus. However, short of IVF, with careful medication dosing and close monitoring the risk of multiples can be greatly reduced.


I hope this has provided a bit of insight into the very common problem of PCOS.


REFERENCES:


Reproductivefacts.org, The patient education website of the American Society for Reproductive Medicine, Polycystic Ovary Syndrome (PCOS).


UpToDate.com, Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics).

First Steps Fertility and Women's Health, 2019

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