POLYCYSTIC OVARY SYNDROME

Polycystic ovary syndrome (PCOS, also known clinically as Stein-Leventhal syndrome), is an endocrine disorder that affects 5-10% of women. It occurs amongst all races and nationalities, is the most common hormonal disorder among women of reproductive age, and is a leading cause of infertility.

Other names for this disorder include:

• polycystic ovary disease (although this is not correct, as PCOS is characterized as a syndrome rather than a disease)
• functional ovarian hyperandrogenism
• hyperandrogenic chronic anovulation
• ovarian dysmetabolic syndrome
• ovarian androgen excess

PCOS develops when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone - either through the release of excessive luteinizing hormone (LH) by the pituitary gland, or due to high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus.

This syndrome acquired its most widely-used name because a common symptom is multiple (poly) ovarian cysts. These form where egg follicles matured, but were never released from the ovary due to abnormal hormone levels. These generally take on a 'string of pearls' appearance. The condition was first described in 1935 by Dr. Stein and Dr. Leventhal, hence its original name of Stein-Leventhal syndrome.

Although the cause of PCOS is not known, research to date suggests that it may be a genetically-linked condition, and further research into this possibility is currently taking place.

Common symptoms of PCOS include:

• Multiple cysts on the ovaries
• Enlarged ovaries, generally 1.5 to 3 times larger than normal, resulting from multiple cysts
• Thickened, smooth, pearl-white outer surface of ovary
• Chronic pelvic pain, possibly due to pelvic crowding from enlarged ovaries; however, the actual cause is not yet known
• The ratio of LH (Luteinizing Hormone) to FSH (Follicular Stimulating Hormone) is 2:1 or more
• Oligomenorrhea, amenorrhea - irregular/few, or absent, menstrual periods; cycles that do occur may comprise heavy bleeding (check with a gynaecologist, since heavy bleeding is also an early warning sign of endometrial cancer, for which women with PCOS are at higher risk)
• Infertility, generally resulting from chronic anovulation (lack of ovulation)
• Elevated serum (blood) levels of androgens (male hormones), specifically testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS), causing hirsutism and occasionally masculinisation
• Central obesity - 'apple-shaped' obesity centered around the lower half of the torso
• Androgenic alopecia (male pattern baldness)
• Acne/oily skin/seborrhea
• Acanthosis nigricans (dark patches of skin, tan to dark brown/black)
• Acrochordons (skin tags) - tiny flaps of skin
• Prolonged periods of PMS-like symptoms (bloating, mood swings, pelvic pain, backaches)
• Depression and anxiety (it is unclear whether this is caused by the hormonal imbalance, or by the self-esteem problems often experienced by women with PCOS)
• Imbalance of estrogen and progesterone, due to lack of corpora lutea (the corporus luteum is the sac left behind when the ovum is released, and is the primary source of progesterone in a woman who is not pregnant)

In addition, women with PCOS are at risk for the following:

• Endometrial hyperplasia and endometrial adenocarcinoma (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by estrogen
• Insulin resistance/Hypoglycaemia/Type II diabetes, generally thought to be caused by hyperinsulinaemia
• High blood pressure
• Dyslipidaemia (disorders of lipid metabolism - cholesterol and triglycerides)
• Cardiovascular disease

Women with PCOS have a risk of miscarriage that is approximately 5 times higher than other women. As well, many women with PCOS have a difficult time conceiving, due to the irregular cycles and lack of ovulation. However, it is possible for these women to have normal pregnancies with the aid of medication and diet.

It is vital to note that not all women with PCOS have polycystic ovaries, nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one. Diagnosis can be difficult, particularly because of the wide range of symptoms, and the variability of how they present in individuals (which is why this disorder is characterized as a syndrome rather than a disease). There are several blood tests that should be done to diagnose PCOS:

• Fasting comprehensive biochemical and lipid panel
• 2-hour GTT with insulin levels (also called IGTT)
• LH:FSH ratio
• Total testosterone
• DHEAS
• SHBG
• Androstenedione
• Prolactin

Also, a measurement of TSH levels should be done, as a number of women with PCOS also have an under-active thyroid, aggravating the problem with obesity.

As well, other causes of irregular/absent menstruation and hirsutism such as congenital adrenal hyperplasia, Cushing's syndrome, and other pituitary and/or adrenal disorders, should be investigated.

Medical treatment of PCOS used to be directed mainly at the symptoms (ovarian and adrenal suppression, and anti-androgen therapy) and restoring ovulation. Some medications used for these purposes are:

• Oral contraceptives (ovarian suppression) - since these cause regular menstruation, they reduce the risk of endometrial carcinoma
• Spironolactone (anti-androgen therapy) - reduce the excessive hair growth by blocking the effects of male hormones
• Clomiphene citrate with human chorionic gonadotropin or dexamethasone (inducing ovulation)

Recent research suggests that the insulin resistance and over-release of insulin may be the at the root of PCOS. Many women find insulin-sensitising medications such as metformin hydrochloride (Glucophage), pioglitazone hydrochloride (Actos), and rosiglitazone maleate (Avandia) helpful to them. Low-carbohydrate diets and sustained regular exercise are also beneficial. As well, initial research suggests that the risk of miscarriage is significantly reduced when metformin is taken throughout pregnancy (9% as opposed to 45%); however, further research needs to be done in this area.

For patients who do not respond to these and related medications/procedures, the polycystic ovaries can be treated with surgical procedures such as:

• laparoscopy electrocauterization or laser cauterization
• ovarian wedge resection (rarely done now, because it is more invasive and has a 30% risk of adhesions, sometimes very severe, which can obstruct fertility)
• ovarian drilling

External links

• The University of Chicago Center for Polycystic Ovary Syndrome
• The Polycystic Ovarian Syndrome Association (PCOSA)
• Soulcysters.com (support site for women with PCOS)
• International Council on Infertility Information Dissemination - PCOS Frequenty Asked Questions