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Polycystic ovary syndrome involves disruption of the menstrual cycle and a tendency to have high levels of male hormones (androgens).

• Women are typically obese and have irregular or no menstrual periods, and in some, the voice deepens, breast size decreases, and acne and excess body hair develop.
• 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 a progestin alone may help reduce symptoms (including excess body hair) and normalize hormone levels.
• If women wish to become pregnant, losing weight and taking clomipheneSome Trade Names
  CLOMID SEROPHENE
  , sometimes with metforminSome Trade Names
  GLUCOPHAGE
  , may stimulate release of an egg.

Polycystic Ovary Syndrome

Polycystic ovary syndrome affects about 5 to 10% of women. In the United States, it is the most common cause of infertility. It gets its name from the many fluid-filled sacs (cysts) that often develop in the ovaries, causing them to enlarge.

A common cause is excess production of luteinizing hormone by the pituitary gland. The excess luteinizing hormone increases the production of male hormones (androgens). High levels of male hormones increases 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 progesteroneSome Trade Names
CRINONE ENDOMETRIN
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 thickened (a condition called endometrial hyperplasia). Also, the risk of cancer of the lining of the uterus (endometrial cancer) may be increased.

In many women, 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.

Did You Know... Polycystic ovary syndrome is the most common cause of infertility in the United States.

Symptoms

Symptoms typically develop during puberty and worsen with time. Symptoms vary from woman to woman.

In some women, menstrual periods do not start at puberty. Irregular vaginal bleeding or amenorrhea is typical. Thus, these women are not releasing an egg from the ovaries (ovulating). These women also develop symptoms related to the high levels of male hormones—a process 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 are obese. Producing too much insulin contributes to weight gain or 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).

Diagnosis

Often, the diagnosis is based on symptoms. Blood tests to measure levels of hormones such as follicle-stimulating hormone and male hormones are 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, blood pressure and usually blood sugar levels are measured to check for metabolic syndrome. Tests to check Cushing's syndrome are also done. Often, a biopsy of the uterine lining (endometrial biopsy) is done to make sure no cancer is present.

Treatment

The choice of treatment depends on the type and severity of symptoms, the woman's age, and her plans regarding pregnancy.

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.

MetforminSome Trade Names
GLUCOPHAGE
, 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 metforminSome Trade Names
GLUCOPHAGE
and do not wish to become pregnant, they should use birth control.

If women wish to become pregnant, losing weight may help. If not, clomipheneSome Trade Names
CLOMID SEROPHENE
is tried. This drug stimulates ovulation. If clomipheneSome Trade Names
CLOMID SEROPHENE
is ineffective and the woman has insulin resistance, metforminSome Trade Names
GLUCOPHAGE
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 progestin by mouth or a combination oral contraceptive (a birth control pill that contains estrogen and a progestin). Either treatment may reduce the risk of endometrial cancer due to the high estrogen level and help lower the levels of male hormones. However, oral contraceptives are not given to women who have reached menopause or who have other significant risk factors for heart or blood vessel disorders.

Increased body hair can be bleached or removed by electrolysis, plucking, waxing, hair-removing liquids or creams (depilatories), or laser. No drug treatment for removing excess hair is ideal or completely effective. The following may help:

• EflornithineSome Trade Names
  VANIQA
  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.
• SpironolactoneSome Trade Names
  ALDACTONE
  , 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). SpironolactoneSome Trade Names
  ALDACTONE
  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.

Last full review/revision December 2008 by JoAnn V. Pinkerton, MD