Polycystic Ovary Syndrome

What is polycystic ovarian syndrome (PCOS)?
Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal diseases affecting reproductive-aged women. In actuality, PCOS includes a spectrum of disorders rather than a single, discrete disease. Women may experience a variety of signs and symptoms, and, as a result, some women may be inappropriately diagnosed with PCOS. Perhaps, more importantly, in many women the diagnosis is completely missed or even ignored.

One problematic aspect of PCOS is that there is no universally accepted definition for this disease. Most reproductive endocrinologists, however, require the presence of hyperandrogenism (excessive "male" hormones) and chronic anovulation (infrequent or absent ovulation resulting in irregular menstrual cycles) to make the diagnosis. Others require the appearance of multiple small ovarian cysts on a vaginal ultrasound examination. Because other disorders of the ovary, pituitary gland and adrenal gland can mimic the symptoms and appearance of PCOS, these disorders should be excluded before an accurate diagnosis of PCOS can be made.

What are the symptoms of PCOS?
The symptoms of PCOS may include irregular menstrual cycles (long intervals between periods), obesity (found in only half of patients), acne, excessive coarse hair growth, and infertility. Much of the hair growth many women, and sometimes their physicians, consider "abnormal" is not truly the result of excessive male hormones. Hairy arms and legs are not usually the result of abnormal hormone patterns, but rather reflect the woman’s family or ethnic background. "Midline" hair growth (e.g. upper lip, chin, abdomen, between the breasts and/or buttocks) is more suspicious for PCOS. 

Some women with PCOS also have metabolic disturbances characterized by resistance to the hormone insulin. This hormone, produced in the pancreas, stimulates the cells of the body to absorb and utilize glucose, a sugar used by the body as a source of energy. In women with PCOS, the cells of the body are often resistant to insulin action and glucose is not utilized efficiently. It is therefore stored for later use in the form of fat, hence the increased obesity and abnormal glucose levels in some women with PCOS. Interestingly, even some thin women with PCOS exhibit insulin resistance. It is important for women with PCOS to realize that excessive fat tissue, insulin resistance and other hormonal aberrations put them at higher risk for coronary artery disease and diabetes. Furthermore, loss of ovulation and infrequent periods increase their risk for cancer of the uterus. Therefore, PCOS is a potentially serious disease and must not be ignored by women or their physicians.

How is PCOS diagnosed?
While many physicians empirically diagnose a woman with PCOS based on the clinical features mentioned above, proper diagnosis requires obtaining blood samples for a variety of hormones, including those produced by the ovaries, adrenal glands, pituitary gland and thyroid gland. A full physical examination and vaginal ultrasound are also important. Cholesterol, triglyceride, glucose and insulin screening should also be part of a complete evaluation.

What causes PCOS?
The truth is, no one really knows what causes this disease. There is certainly a miscommunication between the hypothalamus (within the brain), pituitary gland (at the base of the brain), ovary and fatty tissue. Where the miscommunication originates from is a matter of great controversy and remains unknown. There is definitely a higher incidence of PCOS within certain families but the genetic basis for the disease has not yet been fully elucidated.

So I have PCOS; what can I do about it?
The treatment of PCOS depends primarily on the symptoms exhibited by the patient and whether or not the patient desires to become pregnant.

• Anovulation and irregular menstrual cycles:
  For women who are not presently interested in childbearing, oral contraceptive (birth control) pills are very effective at providing regular cycles, reducing undesired "male" hormone levels and minimizing the risks of uterine cancer. Progesterone, a hormone produced by the ovaries of ovulatory women, can be used to induce regular cycles.
  
  Those women who desire fertility can be placed on Clomiphene Citrate therapy for 3-4 months. Use of this medication for more than 3 or 4 months is unlikely to result in pregnancy and may waste valuable time. Furthermore, women over age 35 may have a lower response to Clomiphene Citrate and should consider the use of injectable fertility medications in order to more effectively induce ovulation.
• Hirsutism (excess hair growth):
  Besides oral contraceptive pills, other medications are commercially available for the treatment of hirsutism. The most common of these are Spironolactone and Finasteride. They are effective at preventing new hair growth but do not rid the body of existing hair. Therefore, they should be used in conjunction with mechanical hair removal methods such as electrolysis. Also, the effects of these medications on developing fetuses are not well-established and therefore, women should use contraceptive measures while taking these medications.
• Obesity:
  As in other obese women, treatment is based on the restriction of calorie intake and an increase in the performance of aerobic exercise. Women should consult with a nutritionist to create a diet that is low in fat and carbohydrates and provides adequate protein. Low-impact exercise programs (for 30 minutes per day 4-5 times per week) are optimal. Weight-lifting may also be helpful as increased muscle mass increases calorie consumption.
• Insulin resistance and glucose abnormalities: 
  Weight reduction will greatly improve not only insulin resistance, but also help regulate menstrual cycles, improve fertility and reduce male hormone levels. In addition, weight loss will lower the risks of coronary artery disease and uterine cancer. Recently, two medications, Metformin and Troglitazone, have been shown to effectively improve insulin sensitivity in women with PCOS and help regulate menstrual cycles. They can be considered as an adjunct to weight loss and exercise in some patients.

Conclusion
PCOS is a common, varied and complex disease. However, in most patients, it can be managed effectively to help patients improve their fertility and lead healthier lifestyles.

References:

Dr. Daniel Stein is a reproductive endocrinologist at Brooklyn IVF. This article was written in connection with the American Infertility Association’s Symposium on PCOS held on October 17, 1999.