Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome is characterized by slight obesity, irregular or no menstrual periods, and symptoms caused by high levels of male hormones (androgens). It involves disruption of the menstrual cycle and a tendency to have high levels of male hormones (androgens).
Typically, women are obese and develop acne and masculine characteristics—the voice deepens, breast size decreases, and excess body hair appears.
Doctors often base the diagnosis on symptoms, but blood tests to measure hormone levels and ultrasonography may also be done.
Exercise, weight loss, and estrogen plus a progestin or progesterone or a progestin alone may help reduce symptoms (including excess body hair) and restore hormone levels to normal.
If women wish to become pregnant, losing weight and taking clomiphene, sometimes with metformin, may stimulate release of an egg.
Polycystic ovary syndrome affects about 5 to 10% of women. In the United States, it is the most common cause of infertility.
This syndrome gets its name from the many fluid-filled sacs (cysts) that often develop in the ovaries, causing them to enlarge.
In many women with polycystic ovary syndrome, the body’s cells resist the effects of insulin (called insulin resistance or sometimes prediabetes). Insulin helps sugar (glucose) pass into cells so that they can use it for energy. When cells resist its effects, sugar accumulates in the blood, and the pancreas produces more insulin to try to lower sugar levels in the blood. If insulin resistance becomes moderate or severe, diabetes is diagnosed.
What causes polycystic ovary syndrome is not clear. Some evidence suggests that the enzyme controlling the production of male hormones malfunctions. As a result, the production of male hormones (androgens) increases.
High levels of male hormones increase the risk of metabolic syndrome (with high blood pressure, high cholesterol levels, and resistance to the effects of insulin). If male hormone levels remain high, the risk of diabetes, heart and blood vessel disorders, and high blood pressure is increased. Also, some of the male hormones may be converted to estrogen, increasing estrogen levels. Not enough progesterone is produced to balance the increased level of estrogen. If this situation continues a long time, the lining of the uterus (endometrium) may become extremely thick (a condition called endometrial hyperplasia). Also, the risk of cancer of the lining of the uterus (endometrial cancer) may be increased.
Symptoms of polycystic ovary syndrome typically develop during puberty and worsen with time. Symptoms vary from woman to woman.
Typically, menstrual periods do not start at puberty, and the ovaries do not release an egg (that is, women do not ovulate) or release an egg irregularly. Women have irregular vaginal bleeding or no menstrual periods.
Women also develop symptoms related to the high levels of male hormones—called masculinization or virilization. Symptoms include acne, a deepened voice, a decrease in breast size, and an increase in muscle size and in body hair (hirsutism). Hair grows as it does in men (for example, on the chest and face) and may thin at the temples.
Most women with polycystic ovary syndrome are slightly obese, but some are thin. Producing too much insulin contributes to weight gain and makes losing weight difficult. Excess insulin may also cause skin in the armpits, on the nape of the neck, and in skinfolds to become dark and thick (a disorder called acanthosis nigricans).
Often, the diagnosis of polycystic ovary syndrome is based on symptoms.
A pregnancy test is routinely done. Blood tests to measure levels of hormones such as follicle-stimulating hormone and male hormones are also done.
Ultrasonography is done to see whether the ovaries contain many cysts and to check for a tumor in an ovary or adrenal gland. These tumors can produce excess male hormones and thus cause the same symptoms as polycystic ovary syndrome.
In women with this syndrome, doctors measure blood pressure and usually levels of blood sugar and fats (lipids), such as cholesterol, to check for metabolic syndrome, which increases the risk of coronary artery disease.
Doctors may do blood tests to check for Cushing syndrome, which can cause similar symptoms.
Often, a biopsy of the uterine lining (endometrial biopsy) is done to make sure no cancer is present, particularly if women have abnormal vaginal bleeding.
The choice of treatment for polycystic ovary syndrome depends on the following:
If insulin levels are high, lowering them may help. Exercising (at least 30 minutes a day) and reducing consumption of carbohydrates (in breads, pasta, potatoes, and sweets) can help lower insulin levels. In some women, weight loss lowers insulin levels enough that ovulation can begin. Weight loss may help reduce hair growth and the risk of thickening of the uterine lining.
Metformin, which is used to treat type 2 diabetes, may be used to increase sensitivity to insulin so the body does not have to make as much insulin. This drug may help women lose weight, and ovulation and menstrual periods may resume. If women take metformin and do not wish to become pregnant, they should use birth control.
If women wish to become pregnant, losing weight may help. If not, clomiphene (a fertility drug) is tried. This drug stimulates ovulation. If clomiphene is ineffective and the woman has insulin resistance, metformin may help because lowering insulin levels may trigger ovulation. If these drugs are not effective, other fertility drugs may be tried. They include follicle-stimulating hormone (to stimulate the ovaries), a gonadotropin-releasing hormone agonist (to stimulate the release of follicle-stimulating hormone), and human chorionic gonadotropin (to trigger ovulation).
Women who do not wish to become pregnant may take a birth control pill that contains only a progestin or that contains estrogen and a progestin (a combination oral contraceptive). Either treatment may reduce the risk of endometrial cancer due to the high estrogen level, make menstrual periods more regular, and help lower the levels of male hormones. However, estrogen increases the risk of stroke and blood clots in the legs or lungs. Thus, oral contraceptives that contain estrogen are not given to women who have significant risk factors for heart or blood vessel disorders or for blood clots. Using an intrauterine device (IUD) that releases progestin reduces the risk of endometrial cancer but does not make menstrual periods more regular.
Excess body hair can be bleached or removed by electrolysis, plucking, waxing, hair-removing liquids or creams (depilatories), or laser (see also Hairiness : Treatment of Hairiness). No drug treatment for removing excess hair is ideal or completely effective. The following may help:
Eflornithine cream may help remove unwanted facial hair.
Oral contraceptives may help, but they must be taken for several months before any effect, which is often slight, can be seen.
Spironolactone, a drug that blocks the production and action of male hormones, can reduce the amount of unwanted body hair. Side effects include increased urine production and low blood pressure (sometimes causing fainting). Spironolactone may not be safe for a developing fetus, so sexually active women taking the drug are advised to use effective birth control methods.
Cyproterone, a strong progestin that blocks the action of male hormones, reduces the amount of unwanted body hair in 50 to 75% of affected women. It is used in many countries but is not approved in the United States.
Gonadotropin-releasing hormone agonists and antagonists are being studied as treatment for unwanted body hair. Both types of drugs inhibit the production of sex hormones by the ovaries. But both can cause bone loss and lead to osteoporosis.