Understanding Polycystic Ovary Syndrome
By Dr. David Kreiner
Polycystic Ovary Syndrome (PCOS) is a condition in which a woman’s hormones are out of balance. It can disrupt the regularity of the menstrual cycle and make it difficult to get pregnant. PCOS may cause one to have acne as well be associated with a variety of health problems including diabetes, hyperlipidemia, and hypertension.
PCOS is the most common hormonal disorder of reproductive age women, occurring in over 7% of women. The symptoms of PCOS often start during the teen years. Treatment not only helps control the symptoms but assists women attempting to conceive.
The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels. If a woman does not respond normally to insulin, her blood sugar levels rise triggering the body to produce more insulin. Elevated insulin levels stimulate ovaries to produce male sex hormones called androgens. Testosterone is a common androgen and is often elevated in women with PCOS. These androgens block the development and maturation of a woman’s ovarian follicles preventing ovulation disrupting the menstrual cycle resulting in irregular menses and infertility. Androgens may also trigger the development of acne and extra facial and body hair. It will increase lipids in the blood. Elevated blood sugar from insulin resistance can develop into diabetes.
Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.
Ovaries develop numerous small follicles that may appear like cysts which is where the name polycystic ovary comes from. These cysts themselves are not usually harmful but in response to fertility treatment can result in larger cysts that can rupture or twist or result in a condition known as Hyperstimulation syndrome. Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the abdominal cavity and occasionally around the lungs. A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots. Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel the embryo transfer in the stimulation cycle for women at high risk. We often prescribe aspirin to prevent clot formation. To avoid adding to the stimulation we often substitute the standard HCG trigger typically administered 36 hrs prior to the egg retrieval with lupron which stimulates LH production in a woman’s pituitary and acts as a natural less stimulating trigger.
The excessive follicles may lead to many eggs maturing in response to fertility treatment also placing patients who ovulate multiple eggs at a high risk of developing a high-order multiple pregnancy. Due to this unique risk, it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.
A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries. A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes. Hormone assays will also be helpful in making a differential diagnosis.
Treatment starts with regular exercise and a diet including healthy foods with limited carbohydrate intake. This can help lower blood pressure and cholesterol and reduce the risk of diabetes. It can also help with weight loss.
Quitting smoking will help reduce androgen levels and reduce the risk of heart disease. Birth control pills help regulate periods and reduce excess facial hair and acne by increasing the estrogen-androgen ratio. Laser hair removal has also been used successfully to reduce excess hair.
A diabetes medicine called metformin can improve glucose metabolism thereby lowering insulin and blood sugar levels. This can help lower androgen levels, regulate menstrual cycles and improve fertility. Recently, it has been discovered that a supplement, ovasitol containing inositol and myoinositol can also help improve glucose metabolism reducing insulin levels. Fertility medications, in particular, letrozole is often needed in addition to metformin and/or ovasitol to get a woman to ovulate and will assist many women to conceive. The use of gonadotropin hormone injections without egg removal may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use. In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy when associated with a single embryo transfer. Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.
It can be hard to deal with having PCOS. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. Ask your doctor about support groups and for treatment that can help you with your symptoms. Remember, PCOS can be annoying, aggravating and even depressing but it is, fortunately, a very treatable disorder.