Polycystic ovarian syndrome (PCOS) is a condition in which women have a number of small cysts around the edge of the ovaries (polycystic ovaries). They may also have one or more additional symptoms.
Symptoms of PCOS include irregular or infrequent periods, weight gain, acne and excessive hair growth.
Women with PCOS may fail to ovulate or ovulate infrequently leading to sub-fertility.
Polycystic ovaries contain large numbers of harmless cysts that are no bigger than 8mm in diameter. The cysts are egg containing follicles that have not developed properly because of a hormone imbalance. Normal ovaries produce both oestrogens (female hormones) and androgens (male hormones). In PCOS there is an over production of androgens which may lead to acne and/or excessive hair growth on the face and other parts of the body.
Women may have difficulty controlling their weight which may exacerbate the problems with ovulation. Weight reduction may dramatically improve the chances of ovulation and reduce the long term health risks associated with PCOS.
Women with PCOS are more likely to develop diabetes mellitus because their tissues are resistant to insulin. There is also an increased risk of gestational diabetes in pregnancy. In addition there is an increased risk of hypertension (high blood pressure) and of cardio vascular disease due to hyperlipidaemia. There is also a risk of endometrial cancer (cancer of the lining of the womb) later in life if there are very long gaps between menstrual periods.
Diagnosis of PCOS can be confirmed by performing an ultrasound of the pelvis to look at the ovaries. Blood tests can be taken to look at the level of androgens (Testosterone, Sex hormone binding globulin, DHEA and Androstenedione and other hormones including Prolactin, thyroid hormones, anti mullerian hormone, follicle stimulating hormone and lutenising hormone). A fasting glucose test can also be taken in selective cases.
PCOS has a significant impact on physical, psychological and social health. Treatment needs to be tailored according to the needs of the patient.
Weight loss in overweight patients will help to reduce insulin levels and improve hormonal balance. The ideal body mass index should be between 20 and 25. Many symptoms including acne and excess hair growth may improve with weight loss and a normal menstrual pattern with regular ovulation may recommence with this measure alone.
The most appropriate diet for women with PCOS is one that promotes more stable levels of blood sugar and lower levels of insulin. A standard low fat high carbohydrate weight loss diet is not ideal. High intakes of carbohydrates especially refined carbohydrates like sweets, white bread etc will quickly turn to sugar and cause elevated levels of insulin. A low glycaemic index diet which will not cause a rapid rise in blood sugar is better for women with PCOS.
Carbohydrates should be spaced throughout the day to avoid peaks in blood sugar and insulin production. Carbohydrates should be combined with proteins and/or fat rather than be eaten alone. It is also best to avoid carbohydrates that trigger more hunger and cravings.
Drugs may be used to aid weight loss by either reducing gastrointestinal absorption of fats (Orlistat) or by suppressing appetite in the brain (Sibutramine) and bariatric surgery can be considered.
Hormone Treatments for irregular/absent periods
The combined oral contraceptive pill can be given to regulate the menstrual cycle and to reduce the risk of endometrial cancer. The combined oral contraceptive pill supplies cyclical levels of oestrogen and progesterone and also increases the circulating level of sex hormone binding globulin (SHBG) which has the effect of inactivating androgens thereby reducing the symptoms of acne and excess hair growth.
Dianette is a hormone preparation that contains oestrogen and anti-androgen. Dianette is an effective oral contraceptive pill but it is best not used solely for this purpose. It can take a few months of treatment before symptoms of acne or hirsutism resolve and it is recommended that this medicine should be stopped three or four months after symptoms have resolved.
Mirena IUS – this intrauterine contraceptive system releases a very small amount of progesterone each day which counteracts the high oestrogen levels that are often present in women with PCOS. This therefore protects the endometrium (lining of the womb) which in the long term may reduce the chance of developing endometrial cancer.
Metformin is a drug that is normally used to treat Type II Diabetes. The link between PCOS and insulin resistance is well established and using Metformin for this condition may help control the amount of glucose in the blood. It may also decrease the amount glucose you absorb from your food and the amount of glucose made by your liver. Patients may experience gastrointestinal side effects such as nausea, abdominal pain, flatulence and diarrhoea initially after commencing this treatment but the side effects normally disappear within two to three weeks. These side effects may be minimised by taking the drug with food.
Other Anti-androgen Treatments
Spironolactone is normally used for treatment of high blood pressure and fluid retention. However it does have anti-androgenic activity and therefore can be used in women with acne and hirsutism (excess hair growth). Due to the way Spironolactone works only women whose acne has an hormonal basis will see improvements with this medication. Some studies have found that 66% of women who took Spironolactone to have excellent improvement or complete clearing of the skin. When used in combination with oral contraceptives this figure improves to 85%.
Eflornithine cream (Vaniqua) is licensed for the treatment of facial hirsutism in women. It irreversibly inhibits an enzyme (ornithine decarboxylase) involved in controlling hair growth and proliferation. The treatment does not remove hair but slows down hair growth such that users require less frequent hair removal by other methods. Eflornithine improves symptoms of hirsutism reduces darkening of facial skin and reduces associated psychological discomfort. However once treatment stops hair re-grows to pre-treatment levels within eight weeks. Many patients use Vaniqua in combination with other cosmetic treatments such as waxing, electrolysis and laser treatments.
Myo-inositol and Inofolic
Myoinositol is a compound found in every living cell. This is often found at very low levels in patients with PCOS. Replacement of myo-inositol can improve the rates of ovulation from 20% up to 70%per cycle. It may also reduce insulin resistance which may help with weight loss and it can also reduce the production of male hormones thus reducing the incidence of acne and hirsutism.
Clomiphene citrate is a selective oestrogen receptor modulator that can be used to induce ovulation. By blocking oestrogen receptors more follicle stimulating hormone is produced which promotes the development of follicles and therefore eggs within the ovary. The first cycle of treatment should be monitored by ultrasound scan to confirm an adequate follicular and endometrial response. Some patients over respond to therapy producing more than two follicles which gives a higher risk of developing higher order multiple pregnancy (triplets, quadruplets etc). Treatment should normally be for six months only. If conception has not occurred in this time consideration should be given to other treatments such as intrauterine insemination (IUI) or IVF treatment.
For women with PCOS who do not respond to Clomiphene citrate laparoscopic ovarian diathermy can be used. This involves performing a laparoscopy and drilling holes in the ovary using a diathermy needle. This may help to induce ovulation and 80% of couples for up to eight months following treatment.
Gonadotrophin therapy using follicle stimulating hormone is a more powerful way to induce ovulation but this should only be performed by specialists who can monitor the response to treatment.
Clomiphene and gonadotrophin therapy are both associated with a twin pregnancy rate between 10 to 20%.