Dr. Albert Asante Discusses PCOS
Is it possible you have Polycystic Ovary Syndrome (PCOS)?
If you have menstrual irregularity, infertility due to lack of ovulation, and/or progressive hirsutism (abnormal hair growth) since puberty, you should be evaluated for PCOS.
So, what is PCOS?
PCOS is a hormone imbalance disorder that affects 5% –10% of women in the reproductive age group; it is the most common endocrine disorder affecting women in the developed world.
It is a condition in which the ovaries contain many immature follicles (egg-containing structures) that are associated with chronic anovulation and overproduction of androgens (male sex hormones).
Features of PCOS
PCOS is a heterogeneous syndrome with multiple and variable clinical manifestations. Symptoms may include irregular, absent or heavy menstrual periods, excessive growth of central body hair (hirsutism), hair loss (alopecia), acne, and infertility. More than 50% of women with PCOS also are overweight or obese, but that is not part of the definition.
Causes and risk factors
The cause of PCOS remains unknown. However, the familial pattern of PCOS with affected mothers and daughters implies a role for genetic factors. According to one clinical study, approximately 35% of mothers and 40% of sisters of women with PCOS are affected.
How is PCOS diagnosed?
Consistent with the fact that PCOS is a syndrome, no single test is available to establish its diagnosis. The diagnosis is based upon the combination of clinical, ultrasound, and laboratory features.
The Endocrine Society recommends that the so-called Rotterdam criteria should be used to diagnose PCOS. Those criteria are based on finding two of the three cardinal features that characterize PCOS.
The first is hyperandrogenism which is androgen excess and diagnosed either based on a clinical sign, such as hirsutism; this includes some mid-line body hair, primarily on the upper lip, chin, and midline between the breasts. Hyperandogenism can also be diagnosed on the basis of elevated circulating levels of androgens (male sex hormones). The androgen that is most commonly used is testosterone.
The second cardinal feature is ovulatory dysfunction, and that usually manifest as oligomenorrhea or infrequent menstruation. Sometimes this is observed as secondary amenorrhea or total lack of periods for a while.
The third sign is a characteristic of the appearance of the ovaries known as the polycystic ovary. The term ‘polycystic ovary’ is a misnomer because the ovary does not contain true cysts (of note, technically speaking, an ovarian cyst refers to a large, usually > 3 cm, fluid-filled sac). Rather, the ‘polycystic ovary’ contains a lot of very small follicles (each measuring less than 1 cm in size) that have failed to mature and ovulate.
Common conditions that may mimic some of the signs and symptoms of polycystic ovary syndrome must be excluded before a diagnosis of PCOS can be conclusively made. Thus, women suspected of having PCOS will be screened for thyroid dysfunction, prolactin excess, and the onset of non-classical congenital adrenal hyperplasia.
Long-term Health Consequences
The potential health implications of PCOS are lifelong. Women with PCOS are at risk for metabolic syndrome. Metabolic syndrome is when women develop multiple risk factors for cardiovascular disorders. They are also at increased risk for prediabetes or overt diabetes, heart disease, cholesterol abnormalities, infertility and endometrial cancer.
A cross-sectional study from the University of Pennsylvania demonstrated a significant increase in disordered eating and an associated decreased quality of life for women with PCOS. Screening for eating disorders, anxiety and depression in women with PCOS is therefore strongly recommended.
Treatments vary according to the complaints or goals of the patient. Some patients may be concerned primarily with fertility, while others are more concerned about menstrual cycle regulation, hirsutism, or acne. Regardless of the primary goal, PCOS should be treated because of the long-term health risks such as heart disease and uterine cancer.
Lifestyle Modification and Weight Loss
Obesity commonly is associated with PCOS. Weight loss has been shown to improve the hormonal condition of overweight or obese PCOS patients. Although tempting, fad diets and diet pills have not been found to be effective, and in many cases, cause additional health problems.
It is recommended that overweight or obese PCOS women should enroll in a weight-control plan or clinic. Increasing physical activity is an important step in any weight reduction program. Recommendations include three to four exercise periods each week with at least 30 minutes of aerobic exercise.
Extreme cases of obesity that do not respond to behavioral modification, should be considered as candidates for bariatric surgery.
PCOS Treatment for Women Who Do Not Wish To Conceive
Hormonal suppression is the treatment of choice for PCOS-related hyperandrogenism. Unfortunately, however, if treatment is stopped, symptoms usually reappear. Birth control pills is the best hormonal treatment. Birth control pills decrease ovarian hormone production and help reverse the effects of excessive androgen levels. Other contraceptive formulations, including injections and implants of progestin can also be used to suppress ovarian hyperandrogenism.
Spironolactone, alone or combined with birth control pills may be prescribed for patients with persistent hirsutism. Rarely, GnRH analogs may be used to decrease ovarian androgen production.
Patients without hirsutism may take progesterone at regular intervals to ensure cyclic endometrial shedding, to prevent the development of uterine cancer.
PCOS Treatment for Women Who Wish to Conceive
For women with fertility as the primary and immediate goal, ovulation is induced with clomiphene citrate. Clomiphene is simple to use, is relatively inexpensive, and works well to induce ovulation in many patients. Approximately 10% of pregnancies with clomiphene are twins; triplets or more are rare.
For women who consistently fail to ovulate after taking clomiphene (also known as clomiphene-resistant patients), the use of another oral medication, letrozole, may be considered. Recent studies suggest that pregnancy rates achieved with letrozole use are similar to clomiphene citrate. Letrozole is not approved by the FDA for induction of ovulation.
If a patient does not respond to both clomiphene and letrozole, or if they fail to conceive after six ovulatory cycles, gonadotropins may be the next step. Gonadotropins are more expensive and have a higher incidence of side effects such as hyperstimulation (excessive swelling) of the ovaries and a higher rate of multiple pregnancy such as twins or triplets.
In very rare cases, ovulation is not achieved with clomiphene, letrozole or gonadotropins, and ovarian surgery may be tried to stimulate ovulation, or patients may proceed to assisted reproductive technology, such as in vitro fertilization.
PCOS can cause hirsutism, acne, irregular or heavy menstrual periods, lack of ovulation, and infertility. It also is associated with an increased risk of diabetes, uterine cancer, high cholesterol, and heart disease. Dealing with PCOS can be emotionally difficult.
The good news is that significant advances have been made in both understanding and treating PCOS. If you are diagnosed with PCOS or suspect that you have PCOS, your goals and concerns can be addressed here at CRM, in a relatively short period of time, and treatment often is successful.
Norman RJ et al. Polycystic ovary syndrome. Lancet. 2007
Legro RS et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013
Kahsar-Miller MD et al. Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS. Fertil Steril 2001