Polycystic Ovary Syndrome (PCOS)
Polycystic ovary
syndrome is characterized by slight obesity, irregular or no menstrual periods,
and symptoms caused by high levels of male hormones (androgens). It involves
disruption of the menstrual cycle and a tendency to have high levels of male
hormones (androgens).
- Typically, women are obese and develop
acne and masculine characteristics—the voice deepens, breast size
decreases, and excess body hair appears.
- Doctors often base the diagnosis on
symptoms, but blood tests to measure hormone levels and ultrasonography
may also be done.
- Exercise, weight loss, and estrogen plus a
progestin or progesterone or a progestin alone may help
reduce symptoms (including excess body hair) and restore hormone levels to
normal.
- If women wish to become pregnant, losing
weight and taking clomiphene, sometimes with metformin,
may stimulate release of an egg.
Polycystic ovary
syndrome affects about 5 to 10% of women. In the United States, it is the most
common cause of infertility.
Polycystic Ovary Syndrome (PCOS)
Polycystic ovary
syndrome gets its name from the many fluid-filled sacs (cysts) that often
develop in the ovaries, causing them to enlarge.(shown here in the right
ovary).
This syndrome gets its
name from the many fluid-filled sacs (cysts) that often develop in the ovaries,
causing them to enlarge.
Did You Know...
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In many women with
polycystic ovary syndrome, the body’s cells resist the effects of insulin (called insulin resistance
or sometimes prediabetes). Insulin helps sugar (glucose) pass into
cells so that they can use it for energy. When cells resist its effects, sugar
accumulates in the blood, and the pancreas produces more insulin to
try to lower sugar levels in the blood. If insulin resistance becomes
moderate or severe, diabetes is diagnosed.
If women with
polycystic ovary syndrome become pregnant, they have a higher risk of
complications during pregnancy. These complications include gestational
diabetes (diabetes that develops during pregnancy), preterm delivery,
and preeclampsia (a type of high blood pressure that develops during
pregnancy). If women with polycystic ovary syndrome are obese, pregnancy
complications tend to be even worse.
Polycystic Ovary Syndrome
Causes of PCOS
What causes polycystic
ovary syndrome is not clear. Some evidence suggests that the enzyme controlling
the production of male hormones malfunctions. As a result, the production of
male hormones (androgens) increases.
High levels of male
hormones increase the risk of metabolic syndrome (with high blood
pressure, high cholesterol levels, and resistance to the effects of insulin).
If male hormone levels remain high, the risk of diabetes, heart and blood
vessel disorders (including atherosclerosis and coronary artery
disease), and high blood pressure is increased. Also, some of the male hormones
may be converted to estrogen, increasing estrogen levels. Not
enough progesterone is produced to balance the increased level
of estrogen. If this situation continues a long time, the lining of the
uterus (endometrium) may become extremely thick (a condition called endometrial
hyperplasia). Also, the risk of cancer of the lining of the uterus (endometrial
cancer) may be increased.
Polycystic ovary
syndrome may also increase the risk of nonalcoholic fatty liver disease (abnormal
accumulation of fats inside liver cells that is not related to alcohol
consumption).
Symptoms of PCOS
Symptoms of polycystic
ovary syndrome typically develop during puberty and worsen with time. Symptoms
vary from woman to woman.
Typically, menstrual
periods do not start at puberty, and the ovaries do not release an egg (that
is, women do not ovulate) or release an egg irregularly. Women have irregular
vaginal bleeding or no menstrual periods.
Women also develop
symptoms related to the high levels of male hormones—called masculinization or
virilization. Symptoms include acne, a deepened voice, a decrease in breast
size, and an increase in muscle size and in body hair (hirsutism). Hair grows
as it does in men (for example, on the chest and face) and may thin at the
temples.
Most women with
polycystic ovary syndrome are slightly obese, but some are thin. Producing too
much insulin contributes to weight gain and makes losing weight
difficult. Excess insulin due to insulin resistance may
also cause skin in the armpits, on the nape of the neck, and in skinfolds to
become dark and thick (a disorder called acanthosis nigricans).
Acanthosis
Nigricans in Polycystic Ovary Syndrome
In people with
polycystic ovary syndrome, skin in the armpits, on the nape of the neck, and in
skinfolds may become dark and thick (a disorder called acanthosis nigricans).
In dark-skinned people, the skin may have a leathery appearance (bottom photo).
Diagnosis of PCOS
- A doctor's evaluation
- Measurement of hormone levels
- Ultrasonography
Often, the diagnosis
of polycystic ovary syndrome is based on symptoms.
A pregnancy test is
routinely done. Blood tests to measure levels of hormones such as
follicle-stimulating hormone and male hormones are also done.
Ultrasonography is
done to see whether the ovaries contain many cysts and to check for a tumor in
an ovary or adrenal gland. These tumors can produce excess male hormones and
thus cause the same symptoms as polycystic ovary syndrome. Transvaginal
ultrasonography may be done to check for abnormalities in the ovaries.
Transvaginal ultrasonography involves using a small handheld device inserted
through the vagina to view the interior of the uterus.
In women with this
syndrome, doctors measure blood pressure and usually levels of blood sugar and fats
(lipids), such as cholesterol, to check for metabolic syndrome, which increases
the risk of coronary artery disease.
Doctors may also do
imaging tests to check for evidence of coronary artery disease. Imaging tests
include coronary angiography (x-rays of arteries taken after a radiopaque
contrast agent, which can be seen on x-rays, is injected into an artery) and
computed tomography (CT) angiography (2- and 3-dimensional images of blood
vessels taken after a radiopaque contrast agent is injected into a vein).
Doctors may do blood
tests to check for Cushing syndrome, which can cause similar symptoms.
Often, a biopsy of the
uterine lining (endometrial biopsy) is done to make sure no cancer is present,
particularly if women have abnormal vaginal bleeding.
Treatment of PCOS
- Exercise, dietary changes, and weight loss
- Drugs, such as birth control pills, metformin,
or spironolactone
- Treatment of excess body hair and acne
The choice of
treatment for polycystic ovary syndrome depends on the following:
- Type and severity of symptoms
- The woman’s age
- Her plans regarding pregnancy
General measures
If insulin levels
are high, lowering them may help. Exercising (at least 30 minutes a day) and
reducing consumption of carbohydrates (in breads, pasta, potatoes, and sweets)
can help lower insulin levels.
Weight loss may help
with the following:
- Lowering insulin levels enough
that ovulation can begin
- Increasing the chances of becoming
pregnant
- Making menstrual periods more regular
- Reducing hair growth and the risk of
thickening of the uterine lining
However, weight loss
is unlikely to benefit normal-weight women with polycystic ovary syndrome.
Drugs
Women who do not wish
to become pregnant are usually given a birth control pill that contains only a
progestin (a synthetic form of the female hormone progesterone), such
as medroxyprogesterone, or one that contains estrogen and a
progestin (a combination oral contraceptive). Either treatment may
- Reduce the risk of endometrial cancer due
to the high estrogen level
- Make menstrual periods more regular
- Help lower the levels of male hormones
- Slightly reduce excess body hair and acne
However, estrogen
increases the risk of stroke and blood clots in the legs or lungs. Thus, oral
contraceptives that contain estrogen are not given to women who have significant risk
factors for heart or blood vessel disorders or for blood clots. Using an intrauterine
device (IUD) that releases a progestin reduces the risk of endometrial
cancer but does not make menstrual periods more regular.
Metformin, which is used to treat type 2 diabetes, may
be used to increase sensitivity to insulin so the body does not have
to make as much insulin. This drug may help women lose weight, and
ovulation and menstrual periods may resume. If women take metformin and
do not wish to become pregnant, they should use birth control. Metformin has
little or no effect on excess hair growth, acne, or infertility. When metformin is
used, women need to periodically have blood tests to measure glucose (sugar)
and to evaluate kidney and liver function.
Newer drugs that can
help women with polycystic ovary syndrome lose weight include liraglutide (used
to treat type 2 diabetes) and orlistat (used to treat obesity). Orlistat and
inositols (which make insulin act more effectively) may reduce symptoms related
to the high levels of male hormones (such as excess body hair) and lessen
insulin resistance.
If women wish to
become pregnant, losing weight may help. If it does not, clomiphene (a
fertility drug) or letrozole is tried. These drugs stimulate
ovulation. If these drugs are ineffective and the woman has insulin resistance, metformin may
help because lowering insulin levels may trigger ovulation. If none
of these drugs is effective, other fertility drugs may be tried. They include
follicle-stimulating hormone (to stimulate the ovaries), a gonadotropin-releasing
hormone (GnRH) agonists (to stimulate the release of follicle-stimulating
hormone), and human chorionic gonadotropin (to trigger ovulation).
If fertility drugs are
ineffective or if women do not wish to take them, surgery (called ovarian
drilling) may be tried. It is done by laparoscopy. Doctors make smalls
incisions just above or below the navel. They then insert a thin viewing tube
(called a laparoscope) into the abdominal cavity through one incision. Through
another incision, they insert special tools that use an electric current or
laser to destroy small areas of the ovaries that produce male hormones
(androgens). Thus, androgen production is decreased. Decreasing the high levels
of androgens in women with polycystic ovary syndrome can help regulate
menstrual cycles and improve the chances of pregnancy. General anesthesia is
required.
Treatment of excess
body hair
Treatment of excess
body hair includes bleaching or removal by electrolysis, plucking, waxing,
hair-removing liquids or creams (depilatories), or laser. No drug treatment for
removing excess hair is ideal or completely effective. The following may help:
- Eflornithine cream may help remove unwanted facial
hair.
- Oral contraceptives may help, but they must be taken for
several months before any effect, which is often slight, can be seen.
- Spironolactone, a drug that blocks the production and action of male
hormones, can reduce the amount of unwanted body hair. Side effects
include increased urine production and low blood pressure (sometimes
causing fainting). Spironolactone may not be safe for a
developing fetus, so sexually active women taking the drug are advised to
use effective birth control methods.
- Cyproterone, a strong progestin that blocks the action of male hormones,
reduces the amount of unwanted body hair in 50 to 75% of affected women.
It is used in many countries but is not approved in the United States.
Gonadotropin-releasing
hormone agonists and antagonists are being studied as treatment for unwanted
body hair. Both types of drugs inhibit the production of sex hormones by the
ovaries. But both can cause bone loss and lead to osteoporosis.
Losing weight reduces
production of androgens and thus may slow hair growth.
Treatment of acne
Acne is treated
as usual, with drugs such as benzoyl peroxide, tretinoin cream,
antibiotics applied to the skin, or antibiotics taken by mouth.