PCOS (polycystic ovary syndrome) is a chronic condition featured by irregular menstrual periods and sometimes elevated male hormones (androgens) which can cause hirsutism (excessive hairiness), acne or hair loss. It is important to make a distinction between polycystic ovary syndrome, which is always accompanied by elevated male hormones, and polycystic ovaries (PCO) detectable by an ultrasound, which themselves are not dangerous.
Signs and symptoms of PCOS frequently start showing during puberty, but some women start exhibit them only in adulthood. Women often have less than 6-8 menstrual periods in a year and various effects of elevated androgenic hormones. Excessive hairiness in women in locations not normally developed in women, such as face, chest or abdomen (male pattern of body hair) is not unusual. The situation varies from one woman to another – some develop problems with acne, some with hairiness, some irregular periods.
Other problems are also common – women with PCOS are often obese and/or infertile. Infertility is caused by irregular ovulations, i.e. failure to release an egg at the time of expected ovulation. These patients often need medical help with conception. A problem which is not so apparent, but is considered as the most common cause of PCOS, is a so-called insulin resistance (IR), i.e. cell resistance to insulin, while simultaneously a patient increases her insulin production.
Furthermore, women with PCOS are later more prone to develop diabetes, high blood pressure, endometrial cancer and apnea than healthy individuals.
Today there are several types of medicines and procedures that help women with PCOS, but a permanent solution of the problem is impossible with either.
Regardless the above, the condition needs to be monitored, which means that the patients also need to learn as much as possible about their condition and help their doctors in deciding on the course of treatment. Therefore the treatment is adjusted individually, i.e. adapted to the need of individual patients.
What problems might a woman with PCOS face?
- Gaining weight and obesity – approximately half of the women with PCOS will eventually gain weight. Therefore it is immensely important to have a healthy diet and exercise regularly in order to maintain normal weight
- Problems with blood sugar levels which might include the following:
- hyperinsulinemia (insulin overproduction)
- insulin resistance (poor tissue reaction to insulin)
- glucose intolerance (pre-diabetic condition)
- non-insulin dependent diabetes mellitus or diabetes mellitus type 2
Insulin resistance (IR) and hyperinsulinemia may occur with obese women, but also with women with normal weight suffering from PCOS. Until they reach 40, up to 35% of obese women develop glucose intolerance, whereas up to 10% develop diabetes mellitus type 2. These figures are much higher than normally expected with women of that age, and the reason is PCOS.
Glucose intolerance and diabetes can be confirmed with blood tests. Tests measuring IR are inaccurate and unfortunately not completely reliable, particularly when it comes to minor deviations. Therefore, even when your tests do not show IR, we cannot completely rule it out, and a doctor may prescribe medications for IR. With more serious conditions it is sometimes enough to make fasting glucose, but sometimes it is necessary to make a so-called OGTT (oral glucose tolerance test, showing body’s ability to break down glucose), i.e. measuring sugar level after introducing high levels of glucose into your body (a highly sweetened liquid is taken, while blood samples are collected before taking it, and two hours after drinking it). IR, hyperinsulinemia and even glucose intolerance can be kept under control with a proper diet and regular exercises.
- Coronary diseases – IR and obesity increase risks of coronary diseases, i.e. narrowing of arteries bringing blood to the heart. Yet, weight loss and exercising decrease the risk
- Endometrial cancer – women with PCOS do not have regular ovulations, thus no regular menstrual periods so their endometrium is being continuously stimulated for growth, without regular “cleansing” in the form of a period. With time this increases risks of endometrial cancer. Therefore women with irregular periods caused by PCOS should used contraceptive pills or, over the period of 10 days monthly, take progesterone pills (didrogesterone, micronized progesterone, medroxyprogesterone acetate) as they reduce cancer risk.
- Apnea – a complete suspension of breathing for a short period of time; it is assumed that about 30% of women with PCOS suffer from it in their sleep. It is associated with heavy snoring at night, interrupted by short periods of breathing suspension (apnea). Patients with this condition are tired and sleepy in daytime. It is diagnosed by monitoring sleep, and there are treatments available.
How are menstruation disorders treated?
Contraceptive pills – they regulate monthly menstrual periods and thus prevent endometrial cancer. It is important to understand that these regular periods do not mean PCOS was cured because such bleeding is induced by hormones in form of pills. After pills are no longer taken, irregular periods are most likely to occur again. Contraceptive pills also help with excessive hairiness and acne, and since they prevent unwanted pregnancies, they are a good solution for women who are not planning pregnancy. Before prescribing pills, a doctor will conduct an examination and do a Pap test, while ultrasound and blood test may also need to be made.
Progesterone pills – prescription of progesterone pills for 10-14 days monthly also prevent endometrial cancer. Bleeding becomes more regular, and even women attempting to get pregnant may use this treatment with the consent of their doctor. A disadvantage of this therapy is that it does not help with dermal problems (hirsutism, acne) and it does not prevent unwanted pregnancy.
Weight loss – obese women with PCOS should lose about 5-10% of their body weight (e.g. if a woman weighs 80 kilos, she should lose 4-8 kilos) in order to regulate their periods.
Drugs that lower insulin level in blood sometimes help with weight loss, i.e. losing weight with dieting becomes easier.
How are hirsutism and acne treated?
Contraceptive pills – they work through two mechanisms. Regular contraceptive pills reduce production of male hormones in the body, while contraceptive pills created especially for women with PCOS contain antiandrogenic substances diminishing effects of male hormones in the body. Both treatments can slow down and decrease hair growth. Oral contraceptives may also increase acne, although some women may need other external substances or antibiotics, as prescribed by their dermatologist.
How are insulin disorders treated?
By treating insulin disorders it is also possible to reduce production of male hormones in the body and thus indirectly regulate a hormonal balance in the body.
- Weight loss and exercising – this is the simplest, but also the most efficient approach to treating insulin disorders, irregular bleeding and other symptoms of PCOS.
- Drugs for lowering insulin levels – this group of drugs contains metformin, used for patients with diabetes. With some women with PCOS this is a reasonable treatment option. Metformin regulates the cycle in 50% of women with PCOS, in some it even reduces male hormones levels and induces more regular ovulations so women taking this drug have less problems conceiving. It can also help with weight reduction diets. Metformin also reduces risk of early miscarriages and development of gestational diabetes (diabetes developed during pregnancy). However, as metformin has been a recent development in treating PCOS, long-term efficiency and potential side effects are still unknown.
How is infertility treated in cases of PCOS?
Generally speaking if a couple cannot get pregnant after a year of regular and unprotected intercourse (6 months if a woman is 35 or older), a doctor will require various tests – usually hormonal status, cervical screening test, semen analysis and patency of fallopian tubes.
If according to the results the cause of infertility is the absence of ovulation due to PCOS, there are several methods of inducing ovulation.
- As already mentioned, a weight loss if a woman is obese successfully re-establishes ovulation.
- Chlomiphene – this is a drug stimulating ovaries to produce one or more eggs maturing in so-called follicles. Chlomiphene induces ovulation in 80% of women with PCOS, and about 50% of those women will conceive with Chlomiphene therapy. Ovulation can be determined by numerous methods, e.g. folliculometry (an ultrasound scan performed every or every other day in order to determine the exact day of ovulation based on follicle size – commonly ovulation happens when follicles are between 18 – 28 mm), so-called LH-strips (urine strips reactive to luteinizing hormone secreted extensively during ovulation), by measuring basal body temperature – BBT (every morning before getting up temperature is taken orally – during ovulation it rises from under 36.5ºC by half a degree). At first lower dosage is prescribed, and if the patient does not react to the dosage, it is increased.
- Drugs for lowering insulin levels – several studies have shown that these drugs are very efficient in establishing ovulation and achieving pregnancy in women with PCOS. They also seem to prevent early miscarriages. However, as they have been a recent development in treating PCOS, their effects on pregnancy are still unknown so their usage should be terminated in early stage of pregnancy, unless advised otherwise by your doctor.
- Gonadotropin treatment – this is a more aggressive treatment of infertility using drugs containing female hormones, LH and/or FSH, to induce maturation of a higher number of follicles in a single cycle, similarly to Chlomiphene. Women with PCOS are injected with FSH, every day over the period of 10 days, after which they, along with their doctor, decide on the method of assisted fertilisation – if number of follicles is lower, fallopian tubes are patent and semen analysis satisfactory, then a timed intercourse or insemination are advised; if number of follicles is higher, or tubes are blocked or semen analysis poor, IVF (in vitro fertilisation) or IVF/ICSI (intracytoplasmic sperm injection) are recommended. This type of treatment induces ovulation in almost all women and pregnancy in up to 60%. The concern with this treatment is a multiple pregnancy, which is medically more dangerous than a singleton pregnancy, as well as hyperstimulation of ovaries, which may result in emergency.
- Surgical treatment – today it is being used less and less frequently due to its invasive nature and since there are many medical options available. Therefore this procedure, so-called laparoscopic drilling, is performed only in patients who fail to react to any of the previously mentioned treatments. The procedure is performed laparoscopically – polycystic ovaries are poked with an electric instrument to make multiple incisions. This leads to ovulation, but unfortunately the effect is short-term – it lasts for about a year. Women with PCOS have 80-87% chances of getting pregnant after this procedure. This treatment, as well as all other methods of treating PCOS, is less efficient with obese patients. Complications with this procedure may be abdominal adhaesions, damage to ovaries, injuries to bladder and intestines and infections.
Does PCOS increase risks of complications in pregnancy?
It is believed that PCOS increases risk of early miscarriages and development of gestational diabetes in pregnancy. Regardless these facts, if a woman with PCOS is monitored and follows her doctor’s instructions, these risks can be minimized.