Polycystic ovary syndrome

Encyclopedia of Medicine by Mercedes McLaughlin

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Definition

Polycystic ovary syndrome (PCOS) is a condition characterized by the accumulation of numerous cysts (fluid-filled sacs) on the ovaries associated with high male hormone levels, chronic anovulation (absent ovulation), and other metabolic disturbances. Classic symptoms include excess facial and body hair, acne, obesity, irregular menstrual cycles, and infertility.

Description

PCOS, also called Stein-Leventhal syndrome, is a group of symptoms caused by underlying hormonal and metabolic disturbances that affects about 6% of premenopausal women. PCOS symptoms appear as early as adolescence in the form of amenorrhea (missed periods), obesity, and hirsutism, the abnormal growth of body hair.

A disturbance in normal hormonal signals prevents ovulation in women with PCOS. Throughout the cycle, estrogen levels remain steady, LH levels are high, and FSH and progesterone levels are low. Since eggs are rarely or never released from their follicles, multiple ovarian cysts develop over time.

One of the most important characteristics of PCOS is hyperandrogenism, the excessive production of male hormones (androgens), particularly testosterone, by the ovaries. This accounts for the male hair-growth patterns and acne in women with PCOS. Hyperandrogenism has been linked with insulin resistance, the inability of the body to respond to insulin, and hyperinsulinemia (high blood insulin levels), both of which are common in PCOS.

Causes & symptoms

While the exact cause of PCOS is unknown, it runs in families, so the tendency to develop the syndrome may be inherited. The interaction of hyperinsulinemia and hyperandrogenism is believed to play a role in chronic anovulation in susceptible women.

The numbers and types of PCOS symptoms that appear vary between women. These include:

• Hirsutism. Related to hyperandrogenism, this occurs in 70% of women.
• Obesity. Approximately 40-70% of PCOS patients are overweight.
• Anovulation and menstrual disturbances. Anovulation appears as amenorrhea in 50% of patients, and as heavy uterine bleeding in 30% of patients; however, 20% of PCOS patients menstruate normally.
• Male-pattern hair loss. Some PCOS patients develop bald spots.
• Infertility. Achieving pregnancy is difficult in many women with PCOS.
• Polycystic ovaries. Most, but not all, women with PCOS have multiple cysts on their ovaries.
• Skin discoloration. Some women with PCOS have dark patches on the skin.
• Abnormal blood chemistry. Women with PCOS have high levels of low-density lipoprotein (LDL or "bad") cholesterol and triglycerides, and low levels of high-density lipoprotein (HDL or "good") cholesterol.
• Hyperinsulinemia. Some women with PCOS have high blood insulin levels, particularly if overweight.

Diagnosis

PCOS is diagnosed when the patient visits her doctor for treatment of symptoms such as hirsutism, obesity, menstrual irregularities, or infertility. PCOS patients are treated by a gynecologist, a doctor who treats diseases of the female reproductive organs, or a reproductive endocrinologist, a specialist who treats diseases of the body's endocrine (hormones and glands) system and infertility.

PCOS can be difficult to diagnose since its symptoms are similar to those of other diseases, and since all of its symptoms may not occur. The doctor takes a complete medical history, including questions about menstruation and reproduction, and weight gain. Physical examination includes a pelvic examination to determine the size of the ovaries, and visual inspection of the skin for hirsutism, acne, or other changes. Blood tests are performed to measure levels of LH, FSH, estrogens, androgens, glucose, and insulin. A glucose-tolerance test may be administered. An ultrasound examination of the ovaries is performed to evaluate their size and shape. Most insurance plans cover the costs of diagnosing and treating PCOS and its related problems.

Treatment

PCOS treatment is aimed at correcting anovulation, restoring normal menstrual periods, improving fertility, eliminating hirsutism and acne, and preventing future complications related to high insulin and blood lipid (fat) levels. Treatment consists of weight loss, drugs or surgery, and hair removal, depending upon which symptoms are most bothersome, and whether the patient desires pregnancy.

Weight loss

In overweight women, weight loss (as little as 5%) through diet and exercise may correct hyperandrogenism, and restore ovulation and fertility. This is often tried first.

Drugs

Hormonal drugs

Patients who do not want to become pregnant and require contraception (spontaneous ovulation occurs occasionally in PCOS patients) are treated with low-dose oral contraceptive pills (OCPs). OCPs bring on regular menstrual periods and correct heavy uterine bleeding, as well as hirsutism, although improvement may not be seen for up to a year.

If an infertile patient desires pregnancy, the first drug usually given to help induce ovulation is clomiphene citrate (Clomid), which results in pregnancy in about 70% of patients but can cause multiple births. In the 20-25% of women who do not respond to Clomid, other drugs that stimulate follicle development and induce ovulation, such as human menstrual gonadotropin (Pergonal) and human chorionic gonadotropin (HCG), are given; however, these drugs have a lower pregnancy rate (less than 30%), a higher rate of multiple pregnancy (from 5-30%, depending on the dose of the drug), and a higher risk of medical problems. PCOS patients have a high rate of miscarriage (30%), and may be treated with the gonadotropin-releasing hormone agonist leuprolide (Lupron) to reduce this risk.

Since PCOS patients do not have regular endometrial shedding due to high estrogen levels, they are at increased risk for overgrowth of this tissue and endometrial cancer. The drug medroxyprogesterone acetate, when taken for the first 10 days of each month, causes regular shedding of the endometrium, and reduces the risk of cancer. However, in most cases, oral contraceptive pills are used instead to bring about regular menstruation.

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