Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder affecting 10% of the general population or 30% of women with irregular or abnormal menstrual cycles. PCOS prevents the ovaries from producing and releasing oocytes (eggs) on a regular basis. The hormonal imbalances associated with PCOS can cause a woman’s periods to be abnormal and make it difficult to getting pregnant. PCOS can also cause unwanted changes with a woman’s appearance such as excessive hair growth, acne and weight gain. Over time PCOS can lead to serious health issues if left untreated. These health issues include diabetes, endometrial cancer hypercholesterolemia, obesity and hypertension.

Polycystic Ovary Disease is very common. The symptoms usually start in the teenage years. Treatment can help treat the symptoms and prevent long term problems.

What are hormones, and what happens to them in PCOS?

Hormones are chemical messengers in the blood stream that make our internal organs and body work. The female reproductive hormones include Estrogen, Progesterone, Follicle Stimulating Hormone, Luteinizing Hormone and Antimullerian Hormone. The common male reproductive hormone is testosterone. For reasons that are not completely, understood, in PCOS, the reproductive hormones get out of balance. In women with PCOS the male hormone testosterone increases above the normal female range. This high level of testosterone can cause the increased hair growth, acne and changes in the periods seen in women with PCOS. It is the imbalance of the reproductive hormones that causes the signs and symptoms of PCOS. Getting the hormones back in balance is the main goal of treatment for patients with PCOS.

What are the symptoms of PCOS?

Symptoms of PCOS can range from mild to severe, but in general with time the symptoms tend to worsen. The common symptoms include:

• Acne
• Weight gain and trouble losing weight.
• Extra hair on the face and body. Often women get thicker and darker facial hair and more hair on the chest, belly, and back.
• Irregular periods. Often women with PCOS have fewer than ten periods a year. Some women have no periods. Others may have very heavy bleeding.
• Thinning hair on the scalp, in severe cases
• Acanthosis Nigricans (dark brown skin color on the nape of the neck and between the legs)
• Fertility problems, many women who have PCOS have trouble getting pregnant (infertility).
• Depression.

What are the treatment options?

Some options for treatment are listed below. The best treatment option depends upon the patient’s medical history, the hormone levels, a physical exam and the desire to achieve pregnancy.

• Weight loss
• Exercise
• Clomiphene
• Clomiphene with dexamethasone
• Low dose FSH
• Pulsatile GnRH (rarely used)
• Wedge resection – by laparotomy. This is a very old surgical procedure that is rarely performed anymore.
• Ovarian drilling/wedge resection by laparoscopy; rarely performed as this procedure may decrease fertility and does not work well for long term treatment.
• Biguanide/thiazolidinediones (Metformin, Avandia, Actos)
• Metformin and Clomiphene
• Provera withdrawal every month
• Combination oral contraceptive pills
• Antiandrogens/Spironolactone
• 5 reductase inhibitors (Finasteride)
• Ornithine decarboxylase inhibitors (Vaniqa)

How is PCOS diagnosed?

PCOS is a clinical diagnosis (i.e. blood tests do not make the diagnosis the medical history and physical exam are the most important factors in making the diagnosis). Patients with PCOS must meet 2 of 3 criteria:

1. Irregular cycles
2. Signs of androgen excess (acne or excessive hair growth) or a elevated serum testosterone level
3. PCOS appearing ovaries by ultrasound with an experienced ultrasonographer.

Once the diagnosis of PCOS is made by medical history then blood work is done to confirm the diagnosis and rule out other medical problems that can mimic PCOS. Blood work can include an FSH, LH, estrogen, AMH, total testosterone, DHEAS, fasting glucose, hemoglobin A1c, fasting insulin, fasting lipid panel, and ultrasound of your ovaries. Often an endometrial biopsy is performed due to the increased risk for endometrial cancer.

Ultrasound picture of a PCOS appearing ovary

Picture of Acanthosis Nigricans in the nape of the neck