Polycystic Ovarian Syndrome (PCOS)
Polycystic ovarian syndrome (PCOS) is a common hormone disorder that affects 5-10% of women. Like all syndromes, PCOS is a collection of problems that are found together. 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 (also known as hyperandrogenism) and ovaries that have multiple small cysts containing eggs (polycystic).
Because this condition is diagnosed by identifying several different problems, PCOS is diagnosed using a combination of physical exam and history, ultrasound (sonogram), and blood tests.
On exam, women who have PCOS usually complain of irregular or missed menstrual periods or a long time between periods. A high percentage die, and even obese, overweight, have increased hair growth (hirsutism), acne, or be unable to get pregnant. On ultrasound, many women with PCOS have enlarged ovaries with many small cysts. Blood tests may show high blood sugar, high cholesterol levels and or high levels of male hormones.
Risks with PCOS
Some of the risks are related to a woman not ovulating regularly. When regular ovulation doesn’t happen, it interrupts the usual hormone cycle and causes levels of estrogen making the lining of the uterus too thick, causing abnormal bleeding. Over time it can lead to pre-cancerous changes or uterine cancer. This lack of regular ovulation can also make it difficult to get pregnant.
Additionally, metabolic syndrome is common in women with PCOS. Symptoms include extra weight around the middle, high cholesterol, high blood pressure, and insulin resistance/diabetes. Each of these symptoms raises the risk of heart disease.
Moreover, in the long term, women with PCOS have a higher chance of developing medical problems such as type 2 (non-insulin dependent) diabetes, high blood pressure, and heart disease. Even young adolescents and thin women with PCOS may develop these complications. Women with PCOS are also at greater risk of complications during pregnancy, including pregnancy-induced high blood pressure, diabetes during pregnancy (gestational diabetes), preterm birth, and increased fetal and neonatal death.
As many as 70% of women with PCOS have decreased sensitivity to insulin thought due to increased weight. This causes those women to overproduce that hormone. Higher levels of insulin are needed to keep sugar leveles under control in overweight PCOS patients. The resulting high levels of insulin may contribute to excessive production of male hormones testerone and can lead to problems with ovulation (timely release of an egg).
Treatment of PCOS in women not trying to get pregnant
If fertility is not the goal, taking hormone medication usually helps to correct PCOS symptoms. Oral contraceptive pills (the pill) are often taken to reduce extra hair growth and acne. The pill can also make menstrual periods more regular and prevent pregnancy and some types of cancer. Metformin an insulin sensitizing drug can help lower the risk of developing diabetes or metabolic syndrome.
Excess hair and acne can be treated with other medicines that lower male hormones like Spironolactone. Excess hair can also be removed using electrolysis and laser treatment. Losing weight lowers the risk of diabetes and androgen levels in many women with PCOS.
Treatment of the infertile PCOS patient
One way to treat infertility is to cause ovulation using medicine. Clomiphene citrate (clomid) is taken by mouth and has usually been tried first. Letrozole is another oral medicine that can be used and can be particularly helpful in patients with PCOS. If this is unsuccessful, injected fertility medicines called gonadotropins may be given to stimulate the growth of an egg. Women with PCOS must be watched very carefully when these medicines are given because it increases the risk of multiple births and ovarian hyperstimulation
Medical treatment of insulin resistance
Insulin resistance may be suspected based on clinical features such as a darkening of the skin around the neck (Acanthosis Nigracans). Fasting laboratory tests may be performed but are not routinely recommended. If a patient is thought to have insulin resistance, a glucose tolerance test (GTT) should be administered to rule out diabetes.
Weight loss, improved nutrition, and exercise and, behavioral change are very important and should be the first line of therapy for an overweight woman with PCOS. Drugs approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes have shown promise for PCOS. These drugs, known as insulin sensitizing agents, improve the body’s response to insulin.
The best studied insulin sensitizing agent available in the United Stated for women with PCOS is Metformin. Metformin reduces circulating insulin and androgen levels and restores normal ovulation in some women with PCOS. Gastrointestinal irritation, especially diarrhea and nausea, is a common side effect. These symptoms usually improve after a few weeks and can be lessened if the dose is slowly increased.
Lactic acidosis is a rare but serious adverse effect of metformin. This is a build-up of acid in the blood stream caused by ineffective metabolism. It can cause deep and rapid breathing, vomiting, abdominal pain, lethargy and heart-rhythm disturbances. Metformin is not recommended for patients with kidney, lung, liver, or heart disease. Metformin should also be temporarily stopped prior to surgery or X-ray procedures that use intravenous contrast because of the increased risk of lactic acidosis.
Metformin and other thiazolidinediones have been shown to reduce hyperandrogenism and restore ovulation in some PCOS patients.
Pioglitazone is not commonly used for PCOS patients and if needed should be supervised by an experienced physician.
In obese PCOS women, especially those with insulin and glucose problems, bariatric (weight loss) surgery may be an effective treatment. In some, surgery can significantly reduce obesity and reduce or eliminate insulin resistance. However, proper nutrition and exercise are still necessary for continued results.
Surgical Treatment of PCOS
In well selected cases who have been refractory to medical management of PCOS, laparoscopic surgery. Specifically, a small incision is made in the navel and a type of telescope (laparoscope) is passed into the abdomen pelvic cavity to visualize the pelvic structures. Once the ovaries are identified, another instrument is passed to accomplish for multiple punctures into the thickened outer layer of the ovary known as “ovarian drilling”. This process lowers male hormone levels which over time, may normalize menstrual cycle and ovulation.