Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive age women. It affects an estimated seven percent of females. PCOS, sometimes called Stein-Leventhal Syndrome after the physicians who first characterized it in the 1930s, is a common cause of infertility. It is also associated with an increased risk of diabetes and, possibly, cardiovascular disease.

The syndrome usually presents at puberty, with irregular or absent periods. As the term polycystic ovary syndrome suggests, the syndrome often is accompanied by enlarged ovaries containing multiple small painless "cysts" or tiny follicles about 1/4 to 1/2 inch in diameter. A "polycystic" ovary generally is defined as having more than 12 small cysts, or being of increased size.

During a normal menstrual cycle in which a woman ovulates (called ovulatory), a small number of follicles begin to grow. One becomes the biggest, or dominant, follicle. This dominant follicle then ruptures and releases the egg.

In women with PCOS, however, high levels of hormones called androgens halt the normal hormonal process and the egg's development. These halted or arrested follicles--whose appearance (via an ultrasound) is sometimes likened to a string of pearls--form the "cysts" observed in PCOS. Health care professionals rarely remove these benign cysts, usually opting to prescribe lifestyle modifications and medication to treat symptoms.

Many, but not all, women with PCOS will have the polycystic-looking ovaries (two to five times larger than normal ovaries) for which the syndrome is named, but it is possible to be diagnosed with the syndrome without this particular symptom.

While the biochemical imbalances that cause symptoms are becoming better understood, the trigger for PCOS is unknown. Researchers suspect a genetic predisposition plays a role. In some patients with PCOS, excess insulin production, which can result from insulin resistance, stimulates testosterone production (a type of male hormone or "androgen"). Insulin resistance is also a precursor to Type II diabetes.

The most visible symptoms of PCOS stem from excessive levels of androgens, such as testosterone, produced in the ovaries and the adrenal glands. Androgens often are called "male hormones," even though they are found in both men and women. They are usually present at much higher concentrations in men and are an important factor in determining male traits and reproductive activity. Androgens include testosterone, DHT and androstenedione.

Excessive levels of these hormones, a condition called "hyperandrogenism" in women, can lead to some of the most common symptoms of PCOS, including:

Excess body or facial hair ("hirsutism")
Oily skin and acne
Oligo-ovulation (irregular ovulation)
Scalp hair loss and balding
But such symptoms alone are not enough to support a diagnosis of PCOS. They may only indicate hyperandrogenism, which can result from several conditions and can be treated with anti-androgen medications.

Women with PCOS often suffer from poor self image and may also experience depression or anxiety.

Women with PCOS ovulate irregularly and/or infrequently, and often have irregular menstrual periods. If periods are absent, it is important to induce them from time to time, whether through regular courses of the hormone progesterone or progesterone-like drugs, or the daily use of birth control pills or patch (which contains a progesterone-like drug). This is important because progesterone induces the shedding of the uterine lining (i.e., menstruation), preventing the build-up of the uterine lining and reducing the risk of endometrial (uterine) cancer.

PCOS often is a cause of infertility due to failure to ovulate. The usual course of treatment is a drug called clomiphene citrate (Clomid, Serophene), a medication used to treat infertile women with ovulation problems. Clomiphene works by helping the pituitary gland improve the stimulation of developing follicles (eggs) in the ovaries. If that doesn't work, the usual next step is injectable gonadotropins, medical preparations of naturally occurring hormones that stimulate the ovaries to produce hormones and prepare eggs for release.

Many health care professionals are increasingly prescribing insulin-sensitizing drugs designed to treat diabetes, such as metformin (Glucophage) to induce ovulation with or without clomiphene. Note that the FDA requires a "black box" warning against prescribing metformin to patients with kidney disease or heart failure that requires drug treatment, and it hasn't been determined whether or not metformin is safe for pregnant women. Discuss these possible risks with your health care professional before taking metformin. Studies indicate such drugs alone or in combination with ovulatory medications such as clomiphene, may be effective for both infertility and other symptoms of PCOS.

Women with PCOS are more likely to be overweight or obese because of their underlying hormonal imbalances. They are also likely to have insulin resistance, in which the body's cells don't respond well to insulin.

Insulin is a hormone produced by the pancreas. With insulin resistance, the pancreas produces excessive amounts of insulin (called "hyperinsulinism" or "hyperinsulinemia").

The excess insulin stimulates the ovaries to overproduce male hormones (called androgens). In some women, it also causes a darkening of the skin around the neck and other crease areas, a condition called "acanthosis nigricans" and often accompanied by skin tags.

If the pancreas can't produce enough insulin to compensate for the insulin resistance, glucose builds up in the blood, eventually leading to type 2 diabetes.

About two-thirds of women with PCOS who are obese have insulin resistance, and many may have type 2 diabetes. Insulin resistance and an increased risk of diabetes is still a problem for normal weight women with PCOS, although less so than for obese patients. For women with PCOS who are obese, a treatment plan incorporates diet and exercise.

Obesity in women with PCOS tends to be centered on the abdomen, a fat distribution pattern linked to increased risk of diabetes, heart disease and high blood pressure.

There is no cure for PCOS. Health care professionals usually address the most bothersome symptoms. Because of the complexity of the hormonal interactions, you may need to see an endocrinologist or a reproductive endocrinologist (especially if you are infertile and trying to conceive).