Polycystic Ovarian Syndrome (PCOS)
Polycystic Ovarian Syndrome (PCOS) is the most common cause of female infertility.
A woman's ovaries have follicles, which are tiny, fluid-filled sacs that hold the eggs. When an egg is mature, the follicle releases the egg so it can travel to the uterus for fertilization. In women with PCOS, immature follicles bunch together to form large cysts or lumps. The eggs mature within the bunched follicles, but the follicles don't break open to release them.
As a result, women with PCOS often don't have menstrual periods, or they only have periods on occasion. Because the eggs are not released, most women with PCOS have trouble getting pregnant. Researchers estimate that 5–10 percent of women in the United States have PCOS.
Here are the most common signs and symptoms of PCOS in teens or adult women:
- Abnormal menstrual cycles
- No periods
- Irregular periods
- Heavy or prolonged bleeding
- Painful periods
- Inability to get pregnant
- Facial hair (more than is normal for the ethnic group)
- Waist measurement greater than 35 inches, or waist bigger than hips (apple shape)
- Acanthosis nigricans: darker patches of skin in neck folds, armpits, folds in waistline, or groin
What Causes PCOS?
No one knows the exact cause of PCOS, but studies are looking at whether it is caused by genetics.
Also, because many women with PCOS also have diabetes, studies are examining the relationship between PCOS and the body's ability to produce insulin. There is a lot of evidence that high levels of insulin contribute to increased production of androgen, which worsens the symptoms of PCOS.
In addition, the medication Valproate, (used to treat seizures) may cause or worsen the symptoms of PCOS.
How is PCOS Diagnosed?
Diagnosing PCOS involves several steps.
Your doctor will take a detailed medical history about your menstrual cycle and reproductive history, including information about birth control you use and any pregnancies you have had.
You also will receive a pelvic and physical exam. During a pelvic exam, your doctor checks for swelling of cysts on your ovary. If cysts are found, your doctor may perform a vaginal ultrasound, or a screening to examine the cysts and the endometrium (lining of the uterus).
If your doctor suspects you have PCOS, he or she may recommend blood tests to measure hormone levels. Women with PCOS can have high levels of hormones such as testosterone.
Your doctor may check your insulin and glucose levels, to look for diabetes or insulin resistance (inefficient use of insulin in the body). Many women with PCOS have these conditions. Your doctor may also check your levels of cholesterol and triglycerides since they are often abnormal in women with PCOS. Once your doctor makes a diagnosis, you will work together to decide how to best treat and manage your condition.
How Does PCOS Affect Fertility and Pregnancy?
PCOS can negatively affect fertility since it can prevent ovulation. Some women with PCOS have menstrual periods, but do not ovulate.
A woman with PCOS may take fertility drugs, such as Clomid, or inject fertility medications to induce ovulation. Women can also take insulin-sensitizing medications or steroids (to lower androgen levels) to help ovulation take place. Some research also shows that taking low doses of aspirin, which helps prevent blood clotting in the uterine lining and improves blood flow, can improve chances of pregnancy.
There appears to be a higher rate of miscarriage in women with PCOS. The reason for this is being studied. Increased levels of leuteinizing hormone, which aids in secretion of progesterone, may play a role.
Increased levels of insulin and glucose may cause problems with development of the embryo. Insulin resistance and late ovulation (after day 16 of the menstrual cycle) also may reduce egg quality, which can lead to miscarriage.
The best way to prevent miscarriage in women with PCOS is to normalize hormone levels to improve ovulation, and normalize blood glucose and androgen levels. Recently, more doctors are prescribing the drug metformin to help with this.
Since PCOS causes high glucose levels, it can be helpful for pregnant women with PCOS to have earlier screenings for gestational diabetes during pregnancy. Gestational diabetes occurs when a woman's ability to process glucose is impaired. The mother's high blood glucose levels can lead to a large baby, immature lungs, and problems for the mother and child at delivery. A carefully balanced diet and/or insulin injections are generally used to manage gestational diabetes.
Some doctors allow pregnant women with PCOS to continue taking metformin in pregnancy, while others won't prescribe it to women trying to conceive. There is no evidence that it causes birth defects, but the long-term effects on the baby are not known. Women and their doctors should discuss the risks and benefits of medications. Women taking medication usually are monitored more closely. After pregnancy, many women with PCOS develop normal menstrual cycles and find it easier to become pregnant again.
Does PCOS Put Women at Risk for Other Conditions?
Women with PCOS can be at an increased risk for developing several other conditions.
Irregular menstrual periods and the absence of ovulation cause women to produce estrogen, but not progesterone. Without progesterone, which causes the endometrium to shed each month as a menstrual period, the endometrium may grow too much and undergo cell changes. This is a pre-cancerous condition called endometrial hyperplasia.
If the thickened endometrium is not treated, over a long period of time it may turn into endometrial cancer. PCOS also is linked to other diseases that occur later in life, such as insulin resistance, type 2 diabetes, high cholesterol, hardening of the arteries (atherosclerosis), high blood pressure, and heart disease.
Depression or mood swings also are common in women with PCOS. Although more research is needed to find out about this link, there are studies linking depression to diabetes. Therefore, in PCOS, depression may be related to insulin resistance. It also could be a result of the hormonal imbalances and the cosmetic symptoms of the condition. Acne, hair loss, and other symptoms of PCOS can lead to poor self-esteem. Infertility and miscarriages also can be very stressful. Medications that restore the balance to hormone levels or antidepressants can help these feelings.
How is PCOS Treated?
Because there is no cure for PCOS, it needs to be managed to prevent further problems.
There are many medications to control the symptoms of PCOS. Doctors most commonly prescribe birth control pills for this purpose. Birth control pills regulate menstruation, reduce androgen levels, and help to clear acne. Your doctor will talk to you about whether a birth control pill is right for you and which kind to take.
Other drugs can help with cosmetic problems. There also are drugs available to control blood pressure and cholesterol. Progestins and insulin-sensitizing medications can be taken to induce a menstrual period and restore normal cycles. Eating a balanced diet low in carbohydrates and maintaining a healthy weight can help lessen the symptoms of PCOS. Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and using insulin more efficiently.
Although it is not recommended as the first course of treatment, surgery called ovarian drilling is available to treat PCOS. A very small incision is made above or below the navel, and a small instrument called a laparoscope that acts like a telescope is inserted into the abdomen. During laparoscopy, the doctor then can make punctures in the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. The surgery can produce an improvement in hormone levels and ovulation, although the improvement may only last a matter of months.