What is Polycystic Ovarian Syndrome (PCOS)?
PCOS is the most common hormonal reproductive problem in women of childbearing age. PCOS is a health problem that can affect a woman’s menstrual cycle, hormones, insulin production, heart, blood vessels, and appearance — and it can cause infertility. PCOS is diagnosed in about 5-10 percent of women of childbearing age and is the #1 problem of women with irregular periods and little or no ovulation.
Symptoms of PCOS
Women who have PCOS may have typical symptoms but they also may not. In fact, PCOS is often not diagnosed on time and sometimes, not at all. Many women have only a few and others have many symptoms. These are some of the symptoms of PCOS:
- Infrequent menstrual periods, no menstrual periods, and/or irregular bleeding
- Amenorrhea (lack of menstrual periods)
- Anovulation and irregular periods
- Infertility or inability to get pregnant because of not ovulating
- Hirsutism (excessive hair growth on the face, chest, abdomen, etc.)
- Hair loss (androgenic alopecia, in a classic "male baldness" pattern)
- Skin problems, such as acne, oily skin, dark skin patches, or skin tag
- Polycystic ovaries
- Enlarged ovaries
- Increased levels of male hormones (hyperandrogenism)
- Weight gain or obesity, usually carrying extra weight around the waist
- Infertility or reduced fertility
- Pelvic pain
- Insulin resistance
- High blood pressure
- Lipid abnormalities
- Increased growth of hair on the face, chest, stomach, back, thumbs, or toes
- Type 2 diabetes
- High cholesterol
- High blood pressure
- Male-pattern baldness or thinning hair
- Patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
- Skin tags, or tiny excess flaps of skin in the armpits or neck area
- Sleep apnea, excessive snoring, and breathing stops at times while asleep
Causes of PCOS
No one knows the exact cause of PCOS. Women with PCOS frequently have a mother or sister with PCOS. But there is not yet enough evidence to say there is a genetic link to this disorder. Many women with PCOS have a weight problem. So researchers are looking at the relationship between PCOS and the body’s ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches, and other food into energy for the body’s use or for storage. Since some women with PCOS make too much insulin, it’s possible that the ovaries react by making too many male hormones, called androgens. This can lead to acne, excessive hair growth, weight gain, and ovulation problems.
Testing for PCOS
There is no single test to diagnose PCOS. Your doctor will take a medical history, perform a physical exam, possibly including an ultrasound, check your hormone levels, and measure glucose, or sugar levels, in the blood. If you are producing too many male hormones, the doctor will make sure it’s from PCOS. At the physical exam the doctor will want to evaluate the areas of increased hair growth, so try to allow the natural hair growth for a few days before the visit. During a pelvic exam, the ovaries may be enlarged or swollen by the increased number of small cysts. This can be seen more easily by vaginal ultrasound, or screening, to examine the ovaries for cysts and the endometrium (the lining of the uterus). The uterine lining may become thicker if there has not been a regular period.
There is no absolute cure for PCOS. Therefore, it needs to be managed to prevent problems. Treatments are based on the symptoms each patient is having and whether she wants to conceive or needs contraception. Here are some treatment for managing PCOS:
Birth Control Pills
For women who don’t want to become pregnant, birth control pills can regulate menstrual cycles, reduce male hormone levels, and help to clear acne. However, the birth control pill does not cure PCOS. The menstrual cycle will become abnormal again if the pill is stopped. Women may also think about taking a pill that only has progesterone, like Provera, to regulate the menstrual cycle and prevent endometrial problems. But progesterone alone does not help reduce acne and hair growth.
The medicine, metformin, also called Glucophage, which is used to treat type 2 diabetes, has been used to induce ovulation in women with PCOS though a recent study showed that is was less effective than clomiphene citrate (Clomid) also helps with PCOS symptoms. Metformin affects the way insulin regulates glucose and decreases the testosterone production. Abnormal hair growth will slow down and ovulation may return after a few months of use. These medications will not cause a person to become diabetic.
The main fertility problem for women with PCOS is the lack of ovulation. However, before beginning fertility medication, a woman should have her partner's sperm count checked and her tubes evaluated to make sure they are open. Clomiphene (pills) and Gonadotropins (shots) can be used to stimulate the ovary to ovulate. PCOS patients are at increased risk for multiple births when using these medications. In vitro Fertilization (IVF) is sometimes recommended to control the chance of having triplets or more. Metformin can be taken with fertility medications and helps to make PCOS women ovulate on lower doses of medication.
Medicine for Increased Hair Growth/Extra Male Hormones
If a woman is not trying to get pregnant there are some other medicines that may reduce hair growth. Spironolactone is a blood pressure medicine that has been shown to decrease the male hormone’s effect on hair. Propecia, a medicine taken by men for hair loss, is another medication that blocks this effect. Both of these medicines can affect the development of a male fetus and should not be taken if pregnancy is possible. Other non-medical treatments such as electrolysis or laser hair removal are effective at getting rid of hair. A woman with PCOS can also take hormonal treatment to keep new hair from growing.
Surgery for PCOS
Although it is not recommended as the first course of treatment, a surgery called ovarian drilling is available to induce ovulation. The doctor makes a very small incision above or below the navel and inserts a small instrument that acts like a telescope into the abdomen. This is called laparoscopy. The doctor then punctures the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But these effects may only last a few months. This treatment doesn't help with increased hair growth and loss of scalp hair.
Healthy Weight for PCOS
Maintaining a healthy weight is another way women can help manage PCOS. Since obesity is common with PCOS, a healthy diet and physical activity help maintain a healthy weight, which will help the body lower glucose levels, use insulin more efficiently, and may help restore a normal period. Even loss of 10% of her body weight can help make a woman's cycle more regular.
How to Get Pregnant with PCOS
The inability getting pregnant in most women with PCOS is usually the consequence of amenorrhea, the absence of ovulation. Anovulation may not be the only reason for many of these problems but you need to ovulate in order to get pregnant.
With PCOS losing weight can often help you to ovulate, the optimal BMI is between 20 and 25. Your doctor may recommend that you try losing weight first before trying any medications to see if ovulation and with it your fertility returns and pregnancy occurs naturally. In addition, being at your optimal weight also improves your chances of having a healthy pregnancy and a healthy baby once you do get pregnant.
Medications for Getting Pregnant with PCOS
The most common treatment for PCOS is Clomid. The American College of Obstetricians and Gynecologists (ACOG) recommends that clomiphene should be the primary medication for PCOS patients with infertility. Clomiphene indirectly causes eggs to mature and be released. One in 10 women who conceive with the aid of clomiphene will have multiple pregnancies, most commonly twins.
- Metformin may also be used alone or together with clomiphene to increase or regulate ovulation in women with PCOS.
- Letrozole slows estrogen production and causes the body to make more follicle-stimulating hormone (FSH), a hormone needed for ovulation. It is as effective as clomiphene in causing ovulation. Studies of letrozole in animals have shown that it causes birth defects if used during pregnancy, but there have been no studies of this drug in pregnant women.
- Gonadotropins are given as an injection an cause ovulation. Gonadotropins have a higher risk of multiple pregnancies than does treatment with clomiphene.
IVF for PCOS
IVF or in vitro fertilization is usually effective in helping women with PCOS get pregnant. With IVF, sperm and an egg are placed in a dish outside the body. The sperm joins with the egg or your doctor helps this process with ICSI intracytoplasmic sperm injection. The fertilized egg is then placed inside the uterus. IVF offers women with PCOS the best chance of getting pregnant. There is more control of lessening the risk of multiple births, but it can be expensive and may not be covered by healthcare insurance.
Pregnancy and PCOS
There appears to be a higher rate of miscarriage, gestational diabetes, pregnancy-induced high blood pressure, and premature delivery in women with PCOS. Researchers are studying how the medicine, metformin, prevents or reduces the chances of having these problems while pregnant, in addition to looking at how the drug lowers male hormone levels and limits weight gain in women who are obese when they get pregnant.
No one yet knows if metformin is safe for pregnant women. Because the drug crosses the placenta, doctors are concerned that the baby could be affected by the drug. Research is ongoing.
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