Polycystic ovary syndrome

POLYCYSTIC OVARY SYNDROME

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are normally present in small amounts in women. The name polycystic ovary syndrome describes the numerous fluid-filled sacs (small cysts) that form in the ovaries. The interesting thing however, is that some women with this disorder do not have cysts, while some women without the disorder do develop cysts.

Ovulation occurs when a mature egg is released from an ovary. This happens so it can be fertilized by a male sperm. If the egg is not fertilized, it is sent out of the body during the menstrual period.

In some cases, a woman doesn't make enough of the hormones needed to ovulate, when ovulation doesn't occur, the ovaries may develop many small cysts. These cysts make hormones called androgens. This account for the high levels of androgens in women with PCOS. The high androgen levels can cause more problems with a woman's menstrual cycle, and it can also cause many of the symptoms of PCOS.

Treatment for PCOS is often done with medication. This helps to reduce symptoms and prevent some health problems but cannot cure PCOS.

TYPES OF PCOS

Polycystic ovarian syndrome, is a hormone-related condition that can affect a woman's period. There are different types of PCOS, it is diagnosed by having 2 out of the following three:

• Elevated androgens (DHEA and/or testosterone),
• Polycystic ovaries on an ultrasound, and
• Ovulatory dysfunction (the lack of ovulation or reduced frequency of ovulation resulting in irregular periods).

PCOS can look different from person to person. While there are different types of PCOS, it's important to remember not to get too caught up with what type one has because the symptoms overlap among all the types of PCOS. This however attests to the fact that PCOS is a collection of symptoms and can show up very differently depending on the person.

The following is a breakdown of the 6 types of PCOS:

• INSULIN-RESISTANT TYPE OF PCOS - With insulin resistant PCOS the body has a decreased ability to properly manage blood sugar. Too much insulin may impair ovulation and that would tell the ovaries to produce more testosterone instead of estrogen. It also stimulates the pituitary gland to make more luteinizing hormone. Balancing blood sugar is very important here with an insulin-resistant type of PCOS.

• INFLAMMATORY TYPE OF PCOS - With an inflammatory type of PCOS the patient can virtually see the inflammation in the body. Signs of inflammation in the body include digestive issues like irritable bowel syndrome (IBS), unexplained fatigue, headaches, and joint pain, skin conditions like eczema or psoriasis, or even food sensitivities.
• POST-PILL TYPE OF PCOS - If a woman meets the diagnostic criteria for PCOS but her menstrual periods were normal before taking hormonal birth control, she may have the post-pill type of PCOS. If she had experienced PCOS symptoms but never received a formal diagnosis before going on the pill, it's possible she has PCOS before going on the pill.
• ADRENAL TYPE OF PCOS - If DHEA-S is the only high androgen (DHEA is a hormone made by the adrenal glands) this can indicate an adrenal type of PCOS as DHEA-S is the adrenal androgen. With this one, the patient will want to check prolactin levels and also rule out another condition that presents symptoms similar to PCOS called nonclassic congenital adrenal hyperplasia (NCAH). This type of PCOS is driven by an abnormal stress response versus an impaired insulin or blood sugar response.
• HIDDEN CAUSE TYPE OF PCOS - Drivers that can result in a hidden cause type of PCOS includes thyroid disease. Hypothyroidism affects ovulation and can worsen insulin resistance, deficiencies in vitamin D, zinc, or iodine, because the ovaries need these nutrients. Another driver could be an elevated prolactin because it can increase DHEA. With these hidden drivers the symptoms should improve pretty quickly once the root causes are fixed.
• LEAN TYPE OF PCOS - Struggles with weight can be a symptom of PCOS (especially with insulin-resistant type of PCOS), but it is entirely possible to have a lean type of PCOS in a lean body as well.

CAUSES

Doctors don't know exactly what causes PCOS. It is the general belief that high levels of male hormones prevent the ovaries from producing hormones and making eggs normally. Genes, insulin resistance, and inflammation have all been linked to excess androgen production.

Genes

Studies have shown that PCOS runs in families. It is thus likely that many genes (not just one) contribute to the condition.

Insulin resistance

Up to about 70 percent of women with PCOS have insulin resistance, meaning that their cells can't use insulin properly. Insulin is a hormone the pancreas produces to help the body use sugar from foods for energy.

When body cells cannot use insulin properly, the body increases demand for insulin. The pancreas makes more insulin to compensate. It is the extra insulin that triggers the ovaries to produce more male hormones.

Obesity is a major cause of insulin resistance. Both obesity and insulin resistance can increase a person's risk for type 2 diabetes.

Inflammation

Women with PCOS often have increased levels of inflammation in their body. Being overweight can also contribute to inflammation. There have been studies that have linked excess inflammation to higher androgen levels

SYMPTOMS OF PCOS

Some of the symptoms of PCOS include:

• Irregular menstrual cycle - Women with PCOS may miss periods or have fewer periods (less than eight in a year). Or, their periods may come every 21 days or more often. Some women with PCOS even stop having menstrual periods.
• Too much hair on the face, chin, or parts of the body where men usually have hair - This is called 'hirsutism.' Hirsutism affects up to 70% of women with PCOS.3
• Acne on the face, chest, and upper back - Acne is a skin condition that occurs when the hair follicles become plugged with oil and dead skin cells. It causes whiteheads, blackheads or pimples.
• Thinning hair or hair loss on the scalp; male-pattern baldness - Thinning hair refers to minor to moderate hair loss
• Weight gain or difficulty with losing weight
• Darkening of skin - particularly along neck creases, in the groin, and underneath breasts
• Skin tags - Small excess flaps of skin in the armpits or neck area

RISK FACTORS

• Genetics May Play a Role in the Risk for PCOS

A woman may be at risk too if her mother or sister has PCOS. There's a strong genetic component to PCOS. It has almost been established that if a woman is diagnosed with PCOS, chances of her sister having it as well is really high. That said, the syndrome may not look exactly the same among family lines; the sister may have a milder form, for instance.

Research also suggests that daughters of women with PCOS are likely to be diagnosed, too, indeed this risk that increases if the mother smoked during pregnancy.

But as much as a genetic link is suspected, it's not concrete enough where doctors can test someone for PCOS genes to care for patients and prevent future symptoms.

• Stress may be both a symptom and a possible cause of PCOS

Clearly, psychological stress is one possible complication of PCOS. After all, these women are more at risk for developing mood problems, like depression and anxiety, and even have a greater risk of suicide, it appears as if stress goes both ways, PCOS causes stress both physically and mentally, which ultimately worsens the hormonal and metabolic imbalances and which could lead to an endless cycle of chronic illness.

Here's exactly how stress can affect one's body

Stress can also play into chronic inflammation, which may directly be behind the symptoms associated with PCOS (i.e. weight gain, acne, infertility) for these reasons, it is critical to put stress-reduction strategies into action in order to decrease this stress-related inflammation when one has PCOS.

• Insulin resistance and PCOS are linked - though unclear how exactly

PCOS is not just about infertility, it causes major metabolic problems as well. The culprit in this case is insulin resistance, which results in high insulin levels. High amounts of insulin also increase the production of androgens, further driving symptoms. Women with PCOS are more likely to have insulin resistance if they're overweight, inactive, or have an unhealthy diet. What is not known is whether insulin resistance causes PCOS development, or if it is PCOS that rather leads to insulin resistance.

Interestingly, there's something curious about insulin resistance. Not all women who have insulin resistance get PCOS. It may instead be a special form of insulin resistance that PCOS women have. Or perhaps certain genes that lead to an excess production of male hormones and insulin. A third option is that early production of male hormones trigger metabolic changes that affect insulin.

• Trouble With Weight Gain or Weight Loss Are 2 Risk Factors for PCOS

Weight gain and the difficulty in losing weight are two signs of PCOS. In fact, many doctors so strongly associate weight problems with the syndrome that they may be quick to diagnose PCOS in a woman who also has irregular periods. Unfortunately, that's not quite enough to make the call because there are thin women who have PCOS. It is clear despite all the mentioned factors, that weight plays a big role in PCOS.

• Sleep Apnea May Play a Role in a Woman's PCOS Risk

Untreated sleep apnea can harm one's health

Many women with PCOS develop sleep apnea, a condition marked by momentary pauses in breathing. Here too, the reason for the link hasn't been confirmed. It may very well be the low levels of progesterone, a hormone that helps relax airways and makes the brain more sensitive to low oxygen concentrations' he says. Essentially progesterone helps detect low oxygen and tells the body to take a breath.

So what's the connection to PCOS? Sleep apnea, exacerbates glucose intolerance and insulin resistance. Even though it is not a cause of PCOS, it can make symptoms worse and increase the risk of complications, like type 2 diabetes.

• Hormonal Birth Control, A Common Treatment for PCOS, May Also Predispose Women to the Condition

Often as a first-line treatment of PCOS, hormonal birth control pills are offered. The flip side however, is that for some women who have never had a problem, they may notice PCOS symptoms after coming off the hormonal birth control pill. There is a new concept in the post-pill syndrome. Indeed these women may have had a predisposition to POCS, but it's the disruption in communication between the pituitary gland and ovaries that set off the symptoms. It's mainly the absence of periods and possibly cysts on their ovaries, which may prompt a doctor to prematurely diagnose a woman with PCOS. But the good news, is that once that anomaly is corrected and ovulation and menstruation resumes, the symptoms go away.

WHEN TO SEE A DOCTOR

See a doctor if one has:

• Been trying unsuccessfully to get pregnant for more than 12 months.
• Missed periods and is sure she is not pregnant.
• Symptoms of PCOS, such as hair growth on the face and body.
• Symptoms of diabetes, such as excess thirst or hunger, blurred vision, or unexplained weight loss.

HOW IS PCOS DIAGNOSED

There is no single test to diagnose PCOS. To help diagnose PCOS and rule out other causes of the symptoms, the doctor may talk discuss the patient's medical history and do a physical exam and different tests:

• Blood tests. Blood tests will be conducted to check androgen hormone levels. The doctor will also check for other hormones related to other common health problems that can be mistaken for PCOS, such as thyroid disease.
• Physical exam. The doctors will measure blood pressure, body mass index (BMI), and waist size. They will also look at the skin for extra facial hair. Chest or back, acne, or skin discoloration. The doctors may look for hair loss or signs of other health conditions (e.g. enlarged thyroid gland).
• Pelvic exam. The doctor may also do a pelvic exam to look for signs of extra male hormones (e.g. an enlarged clitoris) and check to see if the ovaries are not enlarged or swollen.
• Pelvic ultrasound (sonogram). This test uses sound waves to examine a woman's ovaries for cysts and check the lining of the uterus or womb (endometrium).
• The doctor may also test for cholesterol levels and test the patient for diabetes.

After other conditions have been ruled out, the patient may be diagnosed with PCOS if she has at least two of the following symptoms:

• Irregular periods, including periods that come too often, not often enough, or not at all
• Signs that suggest high levels of androgens:
• Extra facial and body hair (hirsutism)
• Thinning of scalp hair
• Multiple cysts on one or both ovaries
• Acne
• Higher than normal blood levels of androgens

TREATMENT

Polycystic ovary syndrome (PCOS) cannot be cured, but the symptoms can be managed. Treatment options can vary because someone with PCOS may experience a range of symptoms, or just one symptom.

Lifestyle changes

In overweight women, the symptoms and overall risk of developing long-term health problems from PCOS can be greatly improved by losing excess weight.

The patient can find out if she is a healthy weight by calculating her body mass index (BMI), which is a measurement of weight in relation to height.

A normal BMI is between 18.5 and 24.9, and patient can lose weight by exercising regularly and eating a healthy, balanced diet.

The patient's diet should include plenty of fruits and vegetables, whole foods (such as whole meal bread, wholegrain cereals and brown rice), lean meats, fish and chicken.

Medicines

A number of medicines are available to treat different symptoms associated with PCOS.

These are described below.

• Irregular or absent periods

The contraceptive pill may be recommended to induce regular periods, or periods may be induced using an intermittent course of progestogen tablets. This will also reduce the long-term risk of developing cancer of the womb lining (endometrial cancer) associated with not having regular periods.

Other hormonal methods of contraception, such as an intrauterine system (IUS), will also reduce this risk by keeping the womb lining thin, but they may not cause periods.

• Fertility problems

With treatment, most women with PCOS are able to get pregnant. The majority of women can be successfully treated with a short course of tablets taken at the beginning of each cycle for several cycles.

If these are not successful, injections or IVF treatment may be offered. There's an increased risk of a multiple pregnancy (usually twins) with these treatments.

The medicine clomiphene is usually the first line of treatment that is recommended for women with PCOS who are trying to get pregnant. Clomiphene encourages ovulation (the monthly release of an egg from the ovaries).

If clomiphene is unsuccessful in encouraging ovulation, Metformin may be recommended. Metformin is a medicine that is often used to treat type 2 diabetes, but it can also lower insulin and blood sugar levels in women with PCOS. As well as stimulating ovulation, encouraging regular monthly periods and lowering the risk of miscarriage, metformin also presents other long-term health benefits (e.g. lowering high cholesterol levels and reducing the risk of heart disease).

Possible side effects of metformin include nausea, vomiting, stomach pain, diarrhea and loss of appetite.

Since metformin has been effective in stimulating fertility, patients must be sure to use suitable contraception if they're sexually active especially, if they're not trying to get pregnant but to use it for PCOS.

Sometimes instead of Clomiphene, Letrozole is used to stimulate ovulation. This medicine can also be used for treating breast cancer.

It must be noted that the use of Letrozole for fertility treatment is 'off-label'. Meaning that the medicine's manufacturer has not applied for a license for it to be used to treat PCOS. In other words, although Letrozole is licensed for treating breast cancer, it does not have a license for treating PCOS.

Sometimes doctors use an unlicensed medicine if they think it would be effective and the benefits of treatment outweigh any associated risks.

In case the patient is unable to get pregnant despite taking oral medicines, a different type of medicine called gonadotropins may be recommended.

These are given by injection. There's a higher risk that they may overstimulate the ovaries and lead to multiple pregnancies.

Unwanted hair growth and hair loss

Medicines to control excessive hair growth (hirsutism) and hair loss (alopecia) include:

Particular types of combined oral contraceptive tablets such as;

• Co-cyprindiol, Dianette, Marvelon and Yasmin
• Cyproterone acetate
• Spironolactone
• Flutamide
• Finasteride

These medicines work by blocking the effects of male hormones, such as testosterone, and some also suppress the production of these hormones by the ovaries.

A cream called Eflornithine can also be used to slow down the growth of unwanted facial hair however, this cream does not remove hair or cure unwanted facial hair, so one may wish to use it alongside a hair removal product.

Improvement may be seen 4 to 8 weeks after treatment with this medicine. If one has unwanted hair growth, she may also want to remove the excess hair by using methods such as plucking, shaving, threading, creams or laser removal.

Other symptoms

Medicines can also be used to treat some of the other problems associated with PCOS, including:

• Orlistat (Weight-loss medicine)
• Statins (Cholesterol-lowering medicine)
• Acne treatments

Surgery

A minor surgical procedure called laparoscopic ovarian drilling (LOD) may be a treatment option for fertility problems associated with PCOS that do not respond to medicine. Under general anaesthetic, the doctor will make a small cut in the lower tummy and pass a long, thin microscope called a laparoscope through into the abdomen.

The ovaries will then be surgically treated using heat or a laser to destroy the tissue that is producing the male hormones.

LOD has been found to lower levels of testosterone and luteinizing hormone (LH), and raise levels of follicle-stimulating hormone (FSH).

This corrects the hormone imbalance and can restore the normal function of the ovaries.

Pregnancy risks

With PCOS, one has a higher risk of pregnancy complications, such as high blood pressure, pre-eclampsia, gestational diabetes and possibly miscarriages.

These risks are particularly high if the person in question is obese. It will therefore be prudent for those who are overweight or obese, to lower their risk by losing weight before trying for a baby.

LIFESTYLE AND HOME REMEDIES

To help decrease the effects of PCOS, try to:

• Maintain a healthy weight. Weight loss can reduce insulin and androgen levels and may restore ovulation.
• Limit carbohydrates. Low-fat, high-carbohydrate diets might increase insulin levels. The doctor can advise about a low-carbohydrate diet if one has PCOS.
• Be active. Exercise helps lower blood sugar levels. Increasing daily activities and participating in regular exercise may treat or even prevent insulin resistance and help keep the weight under control and thus avoid developing diabetes.

KEY POINTS

• PCOS is a very common hormonal problem for women of childbearing age.
• Women with PCOS may be at higher risk for type 2 diabetes, high blood pressure, heart problems, and endometrial cancer.
• With PCOS women may not ovulate, may have high levels of androgens, and have many small cysts on the ovaries.
• PCOS can cause missed periods, irregular menstrual periods, excess hair growth, acne, infertility, and weight gain.
• The treatment regimen for PCOS may depend on whether or not a woman plans to become pregnant. Women who plan to become pregnant in the future may be asked to take different kinds of medications.