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Polycystic ovarian syndrome (PCOS) is a very common condition affecting at least 1 in 7 women of reproductive age. In this article, we look at the symptoms, causes, diagnosis and treatment options available for those women affected.

This article is written by Mr Joe Aquilina, FRCOG, Consultant Gynaecologist Royal London & St. Bartholomew’s Hospitals, London.


Symptoms

Most women have never even heard of PCOS, yet it causes a wide variety of symptoms that often affect female reproductive health in ways that can be truly devastating. Although PCOS often affects the reproductive system, it's important to understand that it is an endocrine system disorder. Polycystic ovarian syndrome can present with a variety of symptoms which include:

  • Irregular periods (cycle greater than 35 days or lack of periods)
  • Infertility; difficulty in becoming pregnant
  • Recurrent miscarriages
  • Unwanted facial and or body hair (hirsutism)
  • Oily skin, acne
  • Being overweight, rapid weight gain especially around the waist and abdomen (known as central obesity)
  • Difficulty in losing weight

The condition is diagnosed when two out of the three following conditions are present:

  1. Lack of periods or periods with a cycle longer than 35 days.
  2. Presence of hirsutism or acne or evidence of high level of male hormone (testosterone) in the blood.
  3. Appearance of polycystic ovaries on ultrasound. The word polycystic is a bit of a misnomer in that the so-called ‘cysts’ in PCOS  are actually in strict scientific terms ‘follicles’ but the original definition has stuck.

2 out of the above 3 criteria are required for an absolute diagnosis of the syndrome.

What are the causes?

The cause of PCOS is not known exactly but probably results from a combination of several related factors.

Women with PCOS frequently have a mother or sister with PCOS. But there is not enough evidence yet to say there is a genetic link to this disorder.

There may be an imbalance between a hormone produced by the brain (pituitary) called luteinizing hormone (LH) and follicle-stimulating hormone (FSH), resulting in a lack of ovulation and an increased testosterone production, a male sex hormone.

Many women with PCOS have a weight problem. So researchers are looking at a relationship between PCOS and the body's ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches and other food into energy for the body's use or for storage. Many women with PCOS have insulin resistance, in which the body cannot use insulin efficiently. Since some women with PCOS make too much insulin, this leads to high circulating blood levels of insulin, called hyperinsulinemia. It is believed that hyperinsulinemia is related to increased levels of male hormones and it is possible that the ovaries react by making too many male hormones, androgens. This can lead to acne, excessive hair growth, weight gain (obesity), and ovulation problems as well as type 2 diabetes. In turn, obesity can increase insulin levels, causing worsening of PCOS. If there is evidence of being overweight a blood test to assess whether there is a tendency to develop diabetes (Oral glucose tolerance test) is sometimes recommended.

Treatment

Lifestyle change and change in diet are absolutely paramount. The long-term consequences of PCOS should also be highlighted. Prophylactic use of a drug call Metformin in women with impaired glucose tolerance to prevent progression of diabetes may be useful in selected cases but this has to be decided by the doctors on a case by case basis at present. The effectiveness of Metformin in relation to ovulation induction has been evaluated and the most recent studies concluded that clomiphene citrate (CC) should still be the first choice therapy for women with therapy naïve PCOS (no previous treatments). In women who do not respond to clomiphene, a combination therapy with Metformin may be considered.

Take home messages

  • The condition never presents itself in exactly the same way in every woman - symptoms are highly variable
  • Not all women with PCOS are infertile
  • Treatment of PCOS is highly individualised
  • Lifestyle changes and exercise are extremely important to manage the condition
  • Metformin is a drug which may have a role in treatment of PCOS and a six-month trial is worthwhile especially in women with PCOS who are overweight
  • For women requesting cycle control, oral contraceptive pill with anti-androgen activity (Yasmin) may be useful
  • Clomiphene is the initial treatment of choice in women who are trying to conceive

Conclusion

PCOS is a very common problem that has both short-term effects upon reproductive function and longer term effects upon the risk of diabetes and cardiovascular disease. Treatment of this condition should not only include drug therapy but also lifestyle changes.

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