PCOS (Polycystic Ovary Syndrome) - Women's Health
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Polycystic Ovarian Syndrome (PCOS) refers to women who present with a variety of complaints including irregular menses; long menstrual cycles; acne; excessive body hair; difficulty keeping weight down and infertility.
Once the diagnosis is confirmed - based on a history, some hormonal blood tests and an ultrasound scan of the pelvis, further management is tailored to meet the patient's priorities eg ovulation stimulation if infertility is the problem; Dianette if acne and excess hair are the dominant problems; metformin with dietary and exercise advice if weight control is the main issue.
A woman is diagnosed with PCOS if she has polycystic ovaries, as seen by ultrasound, in association with one or more of these symptoms - menstrual disturbance (infrequent, irregular or absent menses); subfertility or delayed conception; obesity with difficulty in losing weight; excess body hair (hirsutism) or hair loss; and skin problems including acne, skin tags and darkening of parts of the skin. PCOS is also known as the Stein-Leventhal Syndrome in honour of the men who contributed early insights into the nature of the condition. It is important to recognize that having polycystic ovaries but without symptoms is quite common. Approximately 22% of women will be found to have polycystic ovaries by ultrasound, but PCOS affects 5-10% of women. The cause remains unknown. Although PCOS has many symptoms, the majority of these symptoms do not initially seem interrelated, which can delay diagnosis.
How PCOS develops
In women without PCOS every cycle (usually 28 days) the ovaries begin to develop 20 eggs which mature as little sacs called cysts of follicles. Over the course of the cycle one egg will become dominant and draw most of the hormones being produced. This dominant follicle is then eventually released at midcycle, ready to be fertilized. If fertilization does not occur the egg dies and eventually a period ensues. Women with PCOS fail to produce the correct balance of oestrogen necessary to help one egg become dominant, and as a result the 20 eggs develop but remain as cysts. The latter produce predominantly male hormones or androgens (leading to some of the symptoms – see below) but no progesterone. The build up of androgens and lack of progesterone results in failure to ovulate, absent or irregular menses.
How PCOS is caused
To date, the exact cause of PCOS is unknown. However, ceratin factors appear to play a role in the syndrome including the following: - Insulin resistance: a large number of PCOS suffers are insulin resistant. Insulin resistance occurs when the body’s cells become somewhat “insensitive” to normal levels of insulin, requiring the pancreas to produce more and more insulin to compensate. See below for further details of how insulin resistance is thought to contribute to PCOS. - High luteinizing hormone (LH) relative to follicle stimulating hormone (FSH) levels.FSH is released by the pituitary gland in the brain, and helps the eggs in the ovaries to develop and mature, while LH is important in the process of ovulation itself. - Excessive androgens (male type hormones): most women with PCOS have abnormally high levels of androgens, which are responsible for many of the symptoms such as excessive body hair, acne and failure to ovulate.
Women at risk of developing PCOS
Although the exact cause of PCOS is unknown, there appear to be a number of risk factors including the following: - Having a family history of PCOS (mother or sister) - Being overweight or obese (although this may be a matter of the chicken and egg!) - Having diabetes or insulin resistance (again a matter of the chicken and egg!) - Age range 20 to 30 years.
Symptoms of PCOS
The main symptoms are: (i) menstrual disturbance (ii) sub fertility (iii) obesity (iv) changes in hair growth - hirsutism or loss of hair (v) skin problems. Not all women with PCOS get all the symptoms, and the combination of symptoms, and their severity, varies from woman to woman.
(i) Menstrual disturbance
Around 75% of women with PCOS suffer menstrual disturbance, with infrequent, irregular or absent menses being the common variations. When the menses do come, they are often heavy. The basis of the menstrual disturbance is failure to ovulate on a regular basis associated with a hormonal imbalance. The birth control pill is an effective treatment for the menstrual disturbance, providing regular menstruation and alleviating heavy menses. When given to teenagers, who might have menstrual disturbance not necessarily due to PCOS, the diagnosis of PCOS may often be delayed until after the pill is discontinued.
(ii) Subfertility
Subfertility in women with PCOS is usually due to lack of ovulation described above. However, not all women with PCOS fail to ovulate. Some will ovulate in some cycles but not in others, while some ovulate regularly and conceive naturally. For some women with PCOS, the diagnosis is made for the first time when they fail to conceive. The good news is that the majority of women with PCOS who do not ovulate spontaneously readily respond to ovulation stimulation with simple drugs such as clomid (clomiphene citrate).
(iii) Obesity
About 40% of women with PCOS suffer from being overweight. The hormone changes associated with PCOS render weight loss difficult, and the excess itself exacerbates most of the symptoms of PCOS, creating a vicious cycle. The underlying pathology is a combination of the high levels of androgens and an insulin resistance, but it is not known with certainty s to what causes the obesity. Insulin resistance contributes to obesity by promoting fat storage, but obesity itself contributes to insulin resistance, which in turn exacerbates PCOS symptoms, while high androgen levels also render it difficult to lose weight.
(iv) Changes in hair growth (Hirsutism and hair loss)
Although an excess of body hair growth (hirsutism) is the more common complaint in women with PCOS, in fact some will be troubled by the very opposite symptoms ie hair loss. Both afflictions are a result of an excess of androgens. Androgens, a group of hormones that include testosterone, occur in high levels in men. PCOS women have an excess of these hormones for reasons explained to above. Not all women with PCOS have hirsutism, but 95% of women with hirsutism have PCOS. Women with hirsutism typically have thicker and darker hair growing on their face and face, with the suffers especially bothered by the growth a moustache and/or beard. Other parts of the bosy may also be affected including the arms and legs, pubic region, chest, stomach and back. Some women with PCOS may experience male-pattern baldness (referred to as androgenic alopecia). This is not as common as hirsutism, and fortunately in many sufferers it responds to medical therapy.
(v) Skin problems
The skin problems of PCOS women are caused, yet again, by the high androgen levels. The commonest complaint is acne, which usually develops on the face, particularly along the jaw line, and on the chest and back. An oily skin is a regular feature, and the hormone dihydrotestosterone (or DHT) is thought to be responsible as it stimulates the oil glands, resulting in a greater production of oil, which can clog the pores and cause acne. Additional skin problems in PCOS sufferers include darkening of the skin around the neck, underarms, groin or skin folds; and also skin tags around the armpit area. Tha darkening of the skin is thought to be a symptom of insulin resistance. The skin tags can be easily excised, usually by a dermatologist.
Diagnosing PCOS
Diagnosis is based on taking a careful history, which may yield any of the above symptoms; a physical examination, which may reveal some of the signs such acne, hirsutism and obesity; and special tests including blood tests and transvaginal ultrasound scan of the pelvic organs, which may show the hormonal imbalance, excess androgens, and the tiny cysts around slightly larger than usual ovaries. The blood tests including measuring levels of FSH (follicle-stimulating hormone), LH (luteinizing hormone) and androgens. For both the blood tests results and ultrasound scan assessments, there are internationally agreed criteria on which a diagnosis of PCOS is made. It is important to note that the finding of polycystic ovaries by ultrasound alone does not make the diagnosis of PCOS – symptoms are required.
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