Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome, PCOS, is a condition in which there is a hormonal imbalance within the ovaries. It is a complex condition. In PCOS, the ovaries are bigger than average, and the outer surface of the ovary has an abnormally large number of smaller follicles (these are the sacs of fluid which grow around the egg in response to the stimulating hormones from the brain). In PCOS these follicles remain immature, which means that ovulation rarely happens and so the woman is less fertile.

Women who have PCOS may have the following problems:

• Infertility due to lack of ovulation
• Excessive body hair growth (hirsutism) due to imbalance between hormonesIrregular menstrual cycles and heavy bleeding (cycles which are either less than 21 days or more than 35 days apart) due to lack of ovulation
• Acne
• Obesity

Some women with PCOS may have a higher than normal miscarriage rate if they become pregnant.

While it is not known if women are born with this condition, PCOS seems to run in families. Interestingly, when PCOS is passed down on the man’s side of the family, the men are not infertile, but they do have a tendency to go bald in early life, often before the age of 30. Ongoing research is trying to clarify whether there is a clearly identifiable gene for PCOS. Women are also at risk if they are overweight. Maintaining weight or body mass index (BMI) below a critical threshold is statistically important as weight loss improves hormonal abnormalities and improves the likelihood of ovulation and thus pregnancy.

The diagnosis of PCOS is primarily based on the woman's presenting history and examination. The diagnosis can be confirmed on ultrasound or by measuring the woman's hormonal levels. If the ultrasound and the blood tests are normal it does not mean that the woman does not have the condition. However, it has also been found that women who do not have problems with their periods or or do not have excessive hair growth, can still have ovaries, which on ultrasound, have the appearance of being polycystic.

The treatment of a woman with PCOS will depend on the presenting problems. If a woman presents with irregular heavy bleeding, the oral contraceptive pill (OCP) is the treatment of choice, both to regulate the cycle and to prevent overgrowth of the endometrium (lining of the womb). Progesterone can also be given to replace what is not being produced monthly. If hirsutism (excessive hair growth) is the problem, it can be treated using the OCP as well as with drugs that mitigate testosterone. If these drugs are used, it is most important that the woman use a reliable form of contraception as they may cause genital abnormalities in a male baby if the woman becomes pregnant. If infertility is the problem then clomiphene citrate (Clomid) given orally for 5 days early in the menstrual cycle may induce ovulation. Ovulation can be induced in 80% of women using Clomid and pregnancy rates approach those seen in the normal population (20-25% per month) provided that there are no other factors affecting fertility. The most common side effect with Clomid is hot flushes. The multiple pregnancy rate with Clomid is 5% and the majority of these multiple pregnancies are twin pregnancies.

If Clomid fails to induce ovulation at maximal doses or if the woman has tried Clomid for up to 6 cycles in which she has ovulated but has not become pregnant, follicle-stimulating hormone (FSH) at low doses may be given. Prior to using these drugs the treating doctor will want to (if she/he has not already done so) make sure that the woman's Fallopian tubes are open and that her pelvis is normal. These drugs are given by injection and when the woman uses these drugs she needs to be monitored using blood tests and ultrasounds to make sure that the drugs are not causing her to develop too many eggs. The goal when these drugs are used is to cause only one egg to develop (similar to in a natural cycle).

Nevertheless, the multiple pregnancy rate may be 20-30% with 80% of these multiple pregnancies being twin pregnancies.

Weight loss is also of paramount importance. The disease process may be reversed with loss of weight and there is also evidence that the higher miscarriage rate may decrease to that in the general population with weight loss. A dietician may be required. PCOS can lead to a resistance to insulin, leading to the body producing excessively high levels in an attempt to compensate. This higher level of insulin is known to cause abnormal cholesterol and lipid levels, obesity and an increased likelihood of diabetes. Metformin is a type of drug known as an “insulin-sensitizing agent” which lowers the blood sugar level, in turn reducing the excessively high insulin levels. There have been studies carried out to date, which show the use of insulin-sensitizing drugs as a treatment for PCOS. These suggest that it may well be useful in several areas: helping weight reduction, normalizing blood cholesterol and improving irregular periods (70%) leading to ovulation. One study looking at ovulation in particular found that compared to no treatment, 34% of women ovulated taking Metformin (compared to 4% who did not receive it) and when this was combined with clomiphene it was as high as 90% (compared to 8% who only received clomiphene). The most common side effects during treatment on Metformin are diarrhoea, nausea, vomiting and abdominal bloating.

An operation called ovarian drilling, performed by laparoscopy, can also be used to treat women with PCOS. This operation is usually reserved for women who want to be pregnant, and who have not ovulated on Clomid. In these women it may be used as an alternative to HMG or FSH. During this procedure the ovary is cauterized by drilling into it in a number of spots. We do not know exactly why this procedure works. If the operation is successful the effect may be long lasting.

In a small number of women, PCOS can be a very severe disease in that it can lead to the development of diabetes with all its complications. If the doctor suspects that the woman has this type of illness, she may need to undergo testing to make sure that she is not currently a diabetic. If diabetes is diagnosed, weight loss, diet and the possible use of tablets may be necessary.