Polycystic ovary syndrome

Polycystic ovary syndrome is a condition in which there is an imbalance of a woman's female sex hormones. This hormone imbalance may cause changes in the menstrual cycle, skin changes, small cysts in the ovaries, trouble getting pregnant, and other problems. Causes Female sex hormones include estrogen and progesterone, as well as hormones called androgens. Androgens, often called "male hormones," are also present in women, but in different amounts. Hormones help regulate the normal development of eggs in the ovaries during each menstrual cycle. Polycystic ovary syndrome is related to an imbalance in these female sex hormones. Too much androgen hormone is made, along with changes in other hormone levels. It is not completely understood why or how the changes in the hormone levels occur. Follicles are sacs within the ovaries that contain eggs. Normally, one or more eggs are released during each menstrual cycle. This is called ovulation. In polycystic ovary syndrome, the eggs in these follicles do not mature and are not released from the ovaries. Instead, they can form very small cysts in the ovary. These changes can contribute to infertility. The other symptoms of this disorder are due to the hormone imbalances. Women are usually diagnosed when in their 20s or 30s, but polycystic ovary syndrome may also affect teenage girls. The symptoms often begin when a girl's periods start. Women with this disorder often have a mother or sister who has symptoms similar to those of polycystic ovary syndrome. Symptoms Changes in the menstrual cycle: y y Absent periods, usually with a history of having one or more normal menstrual periods during puberty (secondary amenorrhea) Irregular menstrual periods, which may be more or less frequent, and may range from very light to very heavy

Development of male sex characteristics (virilization): y y y y y Decreased breast size Deepening of the voice Enlargement of the clitoris Increased body hair on the chest, abdomen, and face, as well as around the nipples (called hirsutism) Thinning of the hair on the head, called male-pattern baldness

Other skin changes: y y y Acne that gets worse Dark or thick skin markings and creases around the armpits, groin, neck, and breasts due to insulin sensitivity Exams and TestsDuring a pelvic examination, the health care provider may note an enlarged clitoris (very rare finding) and enlarged ovaries.

Medications used to treat the abnormal hormones and menstrual cycles of polycystic ovary syndrome include: y y Birth control pills or progesterone pills. Weight. can improve the symptoms of PCOS and sometimes will cause the menstrual cycles to normalize. as are weight gain and obesity. Medications or other treatments for abnormal hair growth include: y y y y Birth control pills. Laser removal can be combined with other medicines and hormones. and possibly biopsy the ovaries Treatment Losing weight (which can be difficult) has been shown to help with diabetes. high blood pressure. Sometimes women need this or other fertility drugs to get pregnant. . Levels of different hormones that may be tested include: y y y y y Estrogen levels FSH levels LH levels Male hormone (testosterone) levels 17-ketosteroids Other blood tests that may be done include: y y y y y Fasting glucose and other tests for glucose intolerance and insulin resistance Lipid levels Pregnancy test (serum HCG) Prolactin levels Thyroid function tests Other tests may include: y y Vaginal ultrasound to look at the ovaries Pelvic laparoscopy to look more closely at. body mass index (BMI). and high cholesterol are common findings. Even a weight loss of 5% of total body weight has been shown to help with the imbalance of hormones and also with infertility. Eflornithine cream may slow the growth of unwanted facial hair in women.Diabetes. For some women. to help make menstrual cycles more regular Metformin. This can be expensive and multiple treatments are needed. It may take several months to begin noticing a difference. a medication that increases the body's sensitivity to insulin. high blood pressure. and abdominal circumference are helpful in determining risk factors. Anti-androgen medications. Hair removal using laser and nonlaser light sources damages individual hair follicles so they do not grow back. LH-releasing hormone (LHRH) analogs y Treatment with clomiphene citrate causes the egg to mature and be released. such as spironolactone and flutamide may be tried if birth control pills do not work. and high cholesterol. it can also help with weight loss.

One of the underlying factors is insulin resistance (IR). In writing about PCOS. and add to weight loss when a diet is followed. I wrote this article to put this information together so that it makes sense. also called metabolic or dysmetabolic syndrome. a medication that makes cells more sensitive to insulin. infertility and even depression. Stein-Leventhal syndrome. Possible Complications y y y y Increased risk of endometrial cancer Infertility (early treatment of polycystic ovary disease can help prevent infertility or increase the chance of having a healthy pregnancy) Obesity-related (BMI over 30 and waist circumferance greater than 35) conditions. Yet common as it is. it is understandable! PCOS should not be so hard to diagnose because many of its signs are visible: oily skin and acne.Glucophage (Metformin). Polyfollicular ovarian disease POLYCYSTIC OVARY SYNDROME MAKING PCOS LESS CONFUSING PCOS (polycystic ovary syndrome) is the commonest female hormonal disorder and affects at least 5 to 8% of women ² almost 10 million women in America alone. PCOS can cause irregular periods. Many women with PCOS have difficulty controlling their weight. the basic message is positive: PCOS can be understood and it can be treated. Unfortunately much of it is fragmented or even contradictory. many with PCOS find it baffling ² and so do many doctors. may help make ovulation and menstrual cycles more regular. it is one of the major causes of obesity in women. Outlook (Prognosis) Women who have this condition can get pregnant with the right surgical or medical treatments. Recently. prevent type 2 diabetes. Pregnancies are usually normal. Many of the women I see for PCOS at the Hormone Center of New York have been in just this . Polycystic ovary disease. I have to discuss the problems it causes but no reader should feel discouraged because. THE FRUSTRATION OF PCOS It is frustrating just to have symptoms and even more frustrating when you cannot find anyone who will explain what they mean. increased hair growth on face and body (hirsutism) and loss of scalp hair (androgenic alopecia). Alternative Names Polycystic ovaries. such as high blood pressure. The effects are temporary. more information about PCOS has become available. heart problems. Pelvic laparoscopy to remove a section of the ovary or drill holes in the ovaries is sometimes done to treat the absence of ovulation (anovulation) and infertility. This lack of information is regrettable and unnecessary. Though PCOS is a complex condition. and diabetes Possible increased risk of breast cancer When to Contact a Medical Professional Call for an appointment with your health care provider if you have symptoms of this disorder.

sometimes. Actually PCOS is not one condition but a group of them. some by the LH to FSH ratio. Which of these is most important? The answer is simple: they all are. 4) Shifts in metabolism.have some of the following. THE FOUR (OR FIVE) FEATURES OF PCOS A few years ago I was asked by a group of pharmaceutical scientists to help them devise a computer model for PCOS. they knew something was wrong but could not get their doctors to give them a clear explanation or. These are oily skin and acne. standard diets don·t work.situation. and androgenic alopecia (the female hair loss). even to admit there was a problem. others by the menstrual pattern or the skin and hair changes. Some speculate that PCOS may directly cause depression by an effect on brain chemistry. a situation called anovulation.) This is usually because the ovary does not produce an egg cell (ovum) every month. This is not proven but is almost beside the point because the physical symptoms are discouraging enough in themselves. hirsutism (increased hair growth). Medical diagnosis must be done through consultation with a physician. Your PCOS may be quite different from someone else·s whom you know with the condition. sometimes called androgenic alopecia) This is common with PCOS but many women have hair loss without any of the other changes. Finally I came up with a 4 +1 scheme which I believe helps clarify PCOS and make its individual variation easier to grasp. All these can be risk factors for later heart disease. PCOS does not diminish femininity but its effects -.weight gain. or heavy bleeding.can certainly make a woman insecure about herself. High blood pressure is not uncommon. (This is intended as general information only. 3) Obesity due to difficulty controlling weight. . The extra weight tends to be in the upper body and often the legs are quite thin. Darkening of the skin on the back of neck or underarms (Acanthosis nigricans) Irregular periods (Periods usually more than 5 weeks apart or prolonged. difficulty in getting pregnant -. alopecia (hair loss). 5) The fifth feature is an indirect but very important one: the emotional stress of dealing these physical and metabolic changes.) Very oily skin Persistent acne Facial or body hair that requires more than occasional removal (hirsutism) Loss of scalp hair (alopecia.or someone important to you . So it is important not only to understand the condition in general but to understand how it affects you. Often. A skin change called ACN (acanthosis nigricans) can be a sign of IR. WHO SHOULD HAVE A WORKUP FOR PCOS? If you . Polycystic ovary syndrome (PCOS) has several features. Some of the confusion arises because different doctors focus on different aspects. Some define PCOS by how the ovary looks on ultrasound. 2) Changes in the menstrual cycle (irregular periods) and infertility due to hormone changes inside the ovary. This led me to spend a lot of time thinking how PCOS can be broken down into separate features. hirsutism (increased facial and body hair). and some by insulin levels. principally insulin resistance (IR) and unfavorable cholesterol changes. Here are the 4+1 features of PCOS: 1) Skin and hair changes due to the action of testosterone. you should consider evaluation for PCOS. some by testosterone levels.

the more you will be able to be your own advocate in getting treatment. HOW BAD IS PCOS? This is a question I hear frequently. find out what your PCOS is. Studies have shown that nearly all women with PCOS have some insulin resistance. It acts on the ovary to cause it to make too much testosterone. If you think you have PCOS or have been told you do. Most of the time PCOS is not nearly as bad as it is made to sound. sometimes referred to as upper segment obesity THERE ARE AS MANY FORMS OF PCOS AS THERE ARE WOMEN WITH THE CONDITION If you have several of the features I have listed. causing irregular periods and difficulty getting pregnant. Much of the testosterone goes into the blood stream which carries it throughout the body. Labels are stereotypes and stereotyping tends to hide individual differences. It·s not fair. especially on the upper body and abdomen. It also can cause scalp hair to thin. With PCOS the differences between women with the condition are as important as the similarities. especially if the extra weight is on the upper part of the body or the abdomen. This gets to what is really important: what features of the condition are present and what treatment will best help them. The more you know about PCOS. Insulin causes the body to store energy in the form of fat and carbohydrate. a situation called insulin resistance (IR). the IR gets worse and the pancreas cannot make enough insulin to overcome it. Too much insulin can be just as much a problem as too little. All features of PCOS can be treated effectively. you probably have PCOS. increased hair and alopecia helpful to you. The skin and hair changes in particular can occur without any of the other features. This may stop ovulation. WHAT HAPPENS IN PCOS: INSULIN RESISTANCE. In IR. The most common cause of insulin resistance is being overweight. Weight gain increases IR and IR makes it harder to lose weight. THE NEWEST PIECE OF THE PUZZLE I·ve already mentioned the four features of PCOS. I also see some who have been told that they have PCOS but do not. as we understand it today. the body has a sluggish response to its own insulin and compensates by making more and more. Eventually. or loss of hair from the scalp (alopecia) but no other symptoms of PCOS. Whether to call what you have PCOS or not is less important than getting proper treatment directed at the aspects you do have. Many women have only partial PCOS. WHAT DOES IR DO? When insulin goes up several things happen. You may be wondering. The approach I take is to work out an individual PCOS profile based on the extent to which each of the four features is present. However slender women with PCOS have only a minimal degree that can be detected only by a special research procedure. Later I·ll discuss how IR can be overcome. Unfortunately doctors tend to quibble about the definition. don·t just settle for the diagnosis. The basic problem seems to be that the body becomes resistant to its own insulin. When it reaches the skin. you may find the articles on acne. At this point blood glucose levels start to go up. why do these things tend to happen together? Here·s the story. NOT EVERYONE WHO HAS BEEN TOLD SHE HAS PCOS REALLY HAS IT While I see many women with PCOS who were never told what their problem was. . If you have increased facial or body hair (hirsutism). This results in weight gain.Difficulty controlling weight. the testosterone makes it oily and stimulates hair follicles on the face and body. Medical texts are often misleading because they describe only the most extreme form.

I WAS TOLD MY TESTS ARE NORMAL. In PCOS. It is called ´freeµ because it is not attached to blood proteins and so is free to move into skin and other tissues where it causes its unwanted effects ² acne. Those cysts generally occur one at a time and usually go away in one or two cycles. Workup for PCOS should include testosterone and DHEA-S. Androgens are the so-called male hormones of which testosterone is the most familiar and important. LH is often higher than FSH. High prolactin is a different cause of lack of periods than PCOS and treatment is quite different. Others without cysts in their ovaries do have the other features. the cysts are actually so tiny as to be barely visible. as happens after menopause. (They have nothing to do with the usual ovarian cysts which many women have and which can cause pain or bleeding and sometimes need to be removed. was once thought to be an indirect measure of tissue DHT but has not turned out to be useful. Useful as this test can be. However FSH is normally high just before ovulation. Ultrasound and the ´cystsµ of PCOS One would think from the name. However they have only recently become more widely known. These do not have much effect on their own but can be converted in the body to testosterone. LAB TESTS AND PCOS As I have been emphasizing. Prolactin This is another pituitary hormone. This test is not much use though because results are too variable. A very high value of FSH.Those of us with a long term interest in PCOS have known about the associated metabolic problems for more than a decade. as well as anovulation. a standard 3 hour glucose tolerance test (GTT) is . it helps the breast to make milk. Actually. LH/FSH These are the pituitary hormones which regulate the ovary. help is still available. For both. Best is to get both free and total testosterone measured at the same time. increased hair or alopecia when the blood tests are normal. Others often measured are and androstenedione and DHEA-S. Tests for insulin resistance (IR) The test for IR is a modification of the test for diabetes. However there are several tests which are important to characterize a particular woman·s PCOS. High levels can stop menstruation so it should also be measured when a woman is having infrequent periods. WHAT DOES THAT MEAN? Tests mean nothing until they are correctly interpreted. suggests that the ovary can no longer make eggs and estrogen. hirsutism and alopecia. With PCOS. This skin over-reactivity can be the cause of acne. 3 alpha diol G. PCOS is not really one condition but several and so there is no one test for PCOS. Some tests are not very useful: DHT (dihydrotestosterone) is the activated from of testosterone but blood levels do not reflect what is happening in the skin or ovaries. The most important thing is this: There are treatments which work for acne. There are many kinds of cysts which can form in the body and they have quite different causes. FSH is important for any women whose periods are less than every five weeks to be sure her ovaries are still able to function. The second is the more useful. Some women have many small cysts but regular periods and do not have the four features of PCOS. they can still have unwanted effects on skin and hair. However testosterone can be measured in two forms: total testosterone and free testosterone. This is because some women have skin which is much more sensitive to testosterone than others. increased hair (hirsutism) and alopecia even when all hormone levels are normal! Don·t feel discouraged if your tests are normal. ultrasound is not the proper way to diagnose polycystic ovary syndrome. polycystic ovary syndrome that the cysts in the ovary are very important.) The test used to look for cysts in the ovary is the ultrasound which can be done transabdominally or transvaginally. Even if a woman·s androgens are normal. they are one of the least important features and this is often a point of confusion.

Each of the four possible features is assessed and treatment planned accordingly. oral contraceptives (OCs) usually lower it by about half. adding a testosterone blocker often produces a much better result. SKIN AND HAIR CHANGES: CLEARING ACNE. insulin is measured either fasting or at each time period in addition to glucose. When diabetes is associated with PCOS. No one likes the thought that she might have diabetes but with early recognition and much better medications. (Not every woman with PCOS needs to be tested for diabetes but most do. If testosterone levels are elevated. a cortisone-like medication called dexamethasone can be used in low doses to partially suppress the adrenal so that it makes less testosterone. Not surprisingly earlier diagnosis means more better treatment.done. Sometimes finasteride (Proscar® and Propecia®) is used to prevent the activation of testosterone in the skin. There is no one-size-fits-all treatment for PCOS. The GTT is not particularly popular. The best way to do this depends on where the extra testosterone is coming from. then a drink with 75 g of glucose is taken and more samples are taken at ½. DECREASING UNWANTED HAIR. This depends on weight. not just glucose. This medication should be used only in special circumstances and in very low doses. Recognizing the signs of PCOS means diabetes can be picked up at an earlier. It is important to use one of the several OCs which do not have testosterone-like activity. Blood is taken for glucose. While lowering testosterone can have some benefit on skin and hair changes. This is wrong. When diabetes is caught early. However this is the best test available outside a research laboratory. When the testosterone comes from the adrenal. When it comes from the ovary. Is lowering testosterone enough? Treatments which lower testosterone include oral contraceptives and insulin sensitizers which are discussed in the next section. other signs of PCOS and family history. These help clear acne. It is rare that the sort of diabetes associated with PCOS needs to be treated with insulin injections. So I have found it definitely worthwhile to test early for diabetes in women who have PCOS. In rare situations. The idea has gotten around that diabetes can be diagnosed just with a simple fasting blood glucose level. It takes more than 3 hours. oral medication works better. milder stage. The section on increased hair (hirsutism) tells more about these medications. the outlook has changed dramatically for the better. reduce facial and body hair and ameliorate alopecia. I have tried to be detailed and specific but only in consultation with a doctor can you determine which is right for you. so if you have it done be sure to remind them that you need insulin done. In looking for IR. they are used quite often. WHY IT IS IMPORTANT TO DETECT IR EARLY Frequently. it is essential to avoid . 1. it is usually quite mild and will not show up with just a fasting level. The GTT is so valuable precisely because it can pick up the tendency to diabetes much earlier. treatment usually includes lowering them. In what follows you will find information about treatment of each of the four features of PCOS. Blocking testosterone can be done with medications such as spironolactone (Aldactone®) and certain others which are less commonly used.) TREATING WHAT·S HAPPENING: THE INDIVIDUALIZED PCOS TREATMENT PLAN I find that a comprehensive approach to treating PCOS is best. BRINGING BACK SCALP HAIR The skin and hair changes are due to the effect of testosterone on the oil (sebaceous) glands and hair follicles. Labs are still not used to doing the insulin levels. 2 and 3 hours. There are two parts to this treatment: lowering testosterone and blocking its effects. use of oral medication almost always results in completely normal glucose levels. other medications can be used to suppress the ovary more completely. While these are not labeled for treatment of PCOS. With these as with any other medication which blocks testosterone. I make the initial diagnosis of diabetes in women with PCOS. the glucose drink tastes bad and often does not sit well on an empty stomach.

This can either be an oral contraceptive (all contain a form of progesterone) or a separate medication taken for at least twelve days every one or two months. However. It can be unsafe in people with kidney disease and interacts with . some women are still told that not getting periods does not matter. Any women who is on medication should discuss with her physician ahead of time what to do about the medication when she is trying for pregnancy or pregnant. This is not inevitable however. Despite this. The most common pattern is for periods to come infrequently. sometimes with clots and often crampy. However some women with PCOS have prolonged and heavy periods. ´what is wrong with not having them?µ It is not that periods are good in themselves but rather that regular menses are a sign that hormonal mechanisms are functioning properly. even as little as 20 pounds is the best way to reduce the risk. Losing weight. These medications can reduce IR considerably and may even lessen the chances of going on the actual diabetes. Several new medications can do this. Rather than flog the pancreas. Some simply luck out and do not develop diabetes at all. Periods themselves may not matter but protecting the uterus against cancer matters a lot. Unfortunately. Generally this sort of advice is from physicians who do not take these problems seriously or do not know how to treat them. The various forms of progesterone are discussed in the article on menopausal hormone replacement.pregnancy because there is worry that they might adversely affect development of a male fetus. Irregular periods occur commonly with PCOS because ovulation does not occur every month as it is supposed to. THE NEW MEDICATIONS FOR IR AND EARLY DIABETES Older diabetes medications simply pushed the pancreas to release more insulin to overcome the IR. many women with PCOS are told nothing can be done. GETTING THE CYCLE BACK IN ORDER Since periods are an inconvenience. its best to seek evaluation and treatment rather than waiting to see if they will go away. IRREGULAR PERIODS AND CANCER There is a potentially serious issue with infrequent periods and PCOS. Progesterone is necessary to prepare the uterus to have a normal period. Progesterone protects the lining of the uterus (endometrium) from overgrowth which can lead to cancer. The most commonly used is MPA (medroxyprogesterone acetate or Provera®) but natural progesterone (Prometrium®) can also be used and tends to have fewer side effects. Over time. It is very important that women with PCOS who have irregular periods be treated with a form of progesterone to protect against cancer. Fortunately we now have medications which restore the body·s response to insulin. Not everyone is able to accomplish this however. if a person is overweight. Do not let yourself succumb to pessimism about PCOS! Proper treatment usually can reduce facial and body hair and help scalp hair. Does anything really help with hirsutism or alopecia? Sadly. glucose levels go up in the blood and diabetes develops. they will not affect pregnancy after they have been discontinued for an adequate interval. The one most often used for IR in PCOS is metformin (Glucophage® and Glucophage XR®). For this reason. the ovary does not make progesterone during the second half of the cycle. the endometrium (uterine lining) can get thicker and thicker. it is better to restore the body·s response to insulin. TREATMENT OF INSULIN RESISTANCE Having IR does not necessarily mean that someone has diabetes It does however. Proper progesterone treatment can prevent most cases of endometrial cancer. Shedding in androgenic alopecia can be slowed toward normal and many women get regrowth. Of course. as with any medical treatment. The unfair thing about IR is that not only is it made worse by weight gain. increase the chance that she or he will develop diabetes. One of the appeals of this medication is that it often helps somewhat in losing weight. When months go by with no period. if left alone. Hair may not be restored to the fullest it ever was but often there is enough improvement to reduce the terrible worry that goes with alopecia. alopecia and hirsutism often get worse over time. some women ask. it is like having several at once: heavy. When ovulation does not occur. it makes losing the weight harder. the resistance to insulin tends to increase and when the pancreas can no longer keep up by making more insulin. either on its own or from medication. if you are distressed by them. results vary. particularly if there is a family history. Then when a period does come.

a change in nutrition to high protein. they have not yet been studied with PCOS. Second. or specifically for PCOS. Recent reports suggest that metformin can reduce miscarriages in women with PCOS and may be safe throughout pregnancy.but veg diets can be good for PCOS too. While they have been used to help fertility. before more difficult and expensive treatments such as hormone injections or IVF. before more difficult and expensive treatments such as hormone injections or IVF. Two newer drugs which directly improve the body·s response to insulin are rosiglitazone (Avandia®) and pioglitazone (Actos®). While it is true that PCOS can cause infertility. Some women have few signs of PCOS but develop them during a period of weight gain. Those with regular periods often can conceive without difficulty. Two things can help with this frustrating situation. though not all. Many specialists feel they are the first thing to try. low carbohydrate has made a major difference for many women with PCOS. be sure to tell any doctor or any other health care provider you see that you are on it. As stated before however. A young woman with PCOS should not assume she cannot become pregnant. a different approach is needed ² and it is even harder to find a sympathetic nutritionist -. Research on troglitazone in PCOS showed that it could improve IR and it is likely that the two newer and safer ones have the same effect though so far as I know. it is important to realize that not all women with PCOS have difficulty getting pregnant. There are several books about these diets but in my experience people do much better if they see a professional registered dietitian. Recent reports suggest that metformin can reduce miscarriages in women with PCOS and may be safe throughout pregnancy. Insulin sensitizers restore ovulation in many. Low carb diets require eating meat or fish. troglitazone (Rezulin®) was withdrawn because it could cause serious liver problems.thelowcarblife. A similar medication. they are not FDA approved for this indication. As stated before however. How long to try before considering workup and treatment is individual. One of the best things about insulin sensitizers is that they often restore ovulation and may improve the odds of getting pregnant.com] The dietary establishment is still skeptical about low carb diets ² the American Dietetic Association issued a position statement questioning them ² but they clearly work for many women for whom nothing else works. Many do without any need for treatment and for those who need treatment. INFERTILITY AND PCOS This is a whole subject by itself. Many specialists feel they are the first thing to try. However they are widely used. While they have been used to help fertility. IR promotes weight gain because the higher insulin levels make it harder for the body to break down fat. or specifically for PCOS. One of the best things about insulin sensitizers is that they often restore ovulation and may improve the odds of getting pregnant. The important thing is that treatment of women with PCOS who experience difficulty getting pregnant is improving. the question of whether to continue medication when trying for pregnancy and when pregnant should be discussed in advance with your physician. if at all. And as weight is gained. The two new ones are much safer for the liver but you should discuss the need for monitoring with your doctor. the various symptoms may increase. women with PCOS. although they are not FDA approved for this use at the present time. If you are vegetarian. Women with PCOS who have not conceived within a few months of trying should consult an infertility specialist. the question of whether to continue medication when trying for pregnancy and when pregnant should be discussed in advance with your physician. WEIGHT LOSS AND PCOS Weight is an important factor and in an unfair way because PCOS seems to make the pounds go too quickly and off too slowly. metformin helps somewhat with weight loss in people with IR It is not a ´diet pillµ ² all diet pills have harmful effects and are to be avoided. it is often successful. they are not FDA approved for this indication. [www. First. However they are widely used.certain things such as x-ray dye and general anesthesia. so if you are on metformin. Be careful to get reliable advice about this. The world is full of people whose mothers were told they could not get pregnant! .

the treatment for IR or diabetes in men is the same as that for women with PCOS ² insulin sensitizers. or absent menstrual periods. [edit] Signs and symptoms Common symptoms of PCOS include y y Oligomenorrhea.[1][2][3][4] The principal features are obesity. difficult to understand and difficult to find treatment for. . I think the answer is right in front of us. acne. Things are getting better. But the most important is finding a physician who is aware of recent research and can properly apply the new treatments. few. and excessive amounts or effects of androgenic (masculinizing) hormones. Of course having facial and body hair is normal for men so no one pays attention. The women·s media now recognizes the importance of the condition and carries more information about it.Some specialists think that for women with PCOS. [edit] Nomenclature Other names for this syndrome include polycystic ovarian syndrome (also PCOS). One wonders then. insulin resistance. Men cannot have irregular periods but they can have the metabolic changes. generally resulting from chronic anovulation (lack of ovulation). diabetes. IS THERE A MALE PCOS? PCOS is partly. not used in modern literature). though not entirely. It is well established that taking the pill does not reduce the chances of getting pregnant. anovulation (resulting in irregular menstruation) or amenorrhea. I suspect that many men with adult onset diabetes actually have the equivalent of PCOS. Of course. and obesity are all strongly correlated with PCOS. polycystic ovary disease (PCOD). Polycystic ovary syndrome Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders affecting approximately 5%-10% of women of reproductive age (12±45 years old) and is thought to be one of the leading causes of female subfertility. Significantly. The symptoms and severity of the syndrome vary greatly among women. amenorrhea irregular. ovarian hyperthecosis and sclerocystic ovary syndrome. A FINAL WORD OF ENCOURAGEMENT PCOS can be a difficult condition: difficult to live with . Those men with substantial hair loss. The first step in making life with PCOS tolerable is being able to understand what is happening. who are overweight on the upper part of their body and insulin resistant probably have the male equivalent of PCOS. I·ve noticed that many of the women I see at the Hormone Center of New York have a family history of diabetes. the use of birth control pills to rest the ovary may limit progression of changes and is therefore a good idea in the years before pregnancy is desired. functional ovarian hyperandrogenism. But the most important thing is this: there are now enough options so that any woman with PCOS can find treatment that will make a real difference for her. often in male relatives. Stein-Leventhal syndrome (original name. There is help for all these difficulties however. Infertility. This is not proven but seems sensible for women who have no contraindications for OC use. While the causes are unknown. what about males who inherit genes related to PCOS? While there will probably be no absolute proof until the genes for PCOS have been completely identified. The several year old Polycystic Ovary Syndrome Association is an effective advocacy organization. genetic. many of the hormonal treatments I have discussed are suitable only for women.

Due to its often vague presentation it can take years to reach a diagnosis. giving the appearance of a 'string of pearls'. even when the syndrome is associated with a wide range of symptoms. as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS).[9] PCOS can present in any age during the reproductive years. A clinical prediction rule found that these four questions can diagnose PCOS with a sensitivity of 77. The numerous follicles contribute to the increased size of the ovaries. According to the Rotterdam criteria. testosterone and Dehydroepiandrosterone sulfate may be elevated.essentially a cyst that bursts to release the egg. these symptoms are transient and only reflect the immaturity of the hypothalamicpituitary-ovarian axis during the first years following menarche. o Serum (blood) levels of androgens (male hormones). is meant to be a predictor   . These are believed to be the result of disturbed ovarian function with failed ovulation. specifically for menstrual pattern. that is. there is a so called "follicular arrest". hirsutism.7% 88. After ovulation the follicle remnant is transformed into a progesterone producing corpus luteum. The diagnosis is straightforward using the Rotterdam criteria.[9] The Free androgen index of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high.7%).8% (95% CI 82. No single follicle reach the preovulatory size (16 mm or more). 12 or more small follicles should be seen in an ovary on ultrasound examination. y Standard diagnostic assessments: o History-taking.[11] o ynecologic ultrasonography. several follicles develop to a size of 5 7 mm. are frequent in adolescent girls and are often associated with irregular menstrual cycles. In most instances. insulin resistance and homocysteine levels are significantly higher in subjects having PCOS but have no significant effect on fertility.8% 98. although a pelvic ultrasound is a major diagnostic tool. 1.1% (95% confidence interval [CI] 62. which shrinks and disappears after approximately 12 14 days.[12] The free testosterone level is thought to be the best measure. but not further. In PCOS.e. specifically looking for small ovarian follicles..5 to 3 times larger than normal. o Laparoscopic examination may reveal a thickened. reflected by the infrequent or absent menstruation that is typical of the condition. nor do all women with ovarian cysts have PCOS[citation needed].[8] Approximately three-fourths of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.[13] with ~60% of PCOS patients demonstrating supranormal levels. (This would usually be an incidental finding if laparoscopy were performed for some other reason. including androstenedione. obesity. one egg is released from a dominant follicle .y Hirsutism excessive mild symptoms of hyperandrogenism. it is not the only one. smooth.0%) and a specificity of 93. and the absence of breast development. In normal menstrual cycle. pearl-white outer surface of the ovary. i. The follicles may be oriented in the periphery.[10] [edit] Diagnosis Not all women with PCOS have polycystic ovaries (PCO). such as acne or hypermenorrhea. Serum insulin.

Frank diabetes can be seen in 65 68% of women with this condition.[14] possibly because FAI is correlated with the degree of obesity. PCOS has been reported in other insulin resistant situations such as acromegaly. . The pattern is not very specific and was present in less than 50% in one study. For exclusion of other disorders that may cause similar symptoms: o Prolactin to rule out hyperprolactinemia o TSH to rule out hypothyroidism o 17-hydroxyprogesterone to rule out 21-hydroxylase deficiency (congenital adrenal hyperplasia). low-glycemic diet.5% of those with frank diabetes according to ADA guidelines. Fasting insulin level or GTT with insulin levels (also called IGTT). 7. such as congenital adrenal hyperplasia.[16] There are often low levels of sex hormone binding globulin. hyperprolactinemia. but they can be greatly helped by adrenal suppression with low-dose glucocorticoid therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. and other pituitary or adrenal disorders. history of gestational diabetes) and may indicate impaired glucose tolerance (insulin resistance) in 15-30% of women with PCOS. androgen secreting neoplasms. Many women with normal levels may benefit from combination therapy. The ratio of LH (Luteinizing hormone) to FSH (Follicle stimulating hormone) is greater than 1:1. A mathematical derivation known as the HOMAI. oral glucose tests revealed that up to 38% of asymptomatic women with PCOS (versus 8.5). calculated from the fasting values in glucose and insulin concentrations.5% in the general population) actually had impaired glucose tolerance. as tested on Day 3 of the menstrual cycle.[17] While fasting glucose levels may remain within normal limits. Elevated insulin levels have been helpful to predict response to medication and may indicate women who will need higher dosages of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication. Cushing's syndrome. family history. and exercise. Many such women may appear similar to PCOS and be made worse by insulin resistance or obesity. Insulin resistance can be observed in both normal weight and overweight patients.o of free testosterone. Glucose tolerance testing (GTT) instead of fasting glucose can increase diagnosis of increased glucose tolerance and frank diabetes among patients with PCOS according to a prospective controlled trial. allows a direct and moderately accurate measure of insulin sensitivity (glucoselevel x insulin-level/22.[15] Some other blood tests are suggestive but not diagnostic. but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS. y y Common assessments for associated conditions or risks o Fasting biochemical screen and lipid profile o 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity. particularly among obese women. should be investigated.[17] y y [edit] Differential diagnosis Other causes of irregular or absent menstruation and hirsutism.

PCOS is characterized by a complex set of symptoms. Stein and Dr. hence its original name of SteinLeventhal syndrome.[18] Also. increased ovarian androgen production. . either through the release of excessive luteinizing hormone (LH) by the anterior pituitary gland or through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus. hyperinsulinemia increases GnRH pulse frequency. all these steps lead to the development of PCOS. decreased follicular maturation. However. not cysts ("polyfollicular ovary syndrome" would have been a more accurate name). The condition was first described in 1935 by Dr. LH over FSH dominance. Until further studies have been conducted and the research collaborated there is no assumption that female homosexuality will increase the occurrence of PCOS. with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms. and further research into this possibility is taking place. Adipose tissue possesses aromatase. an enzyme that converts androstenedione to estrone and testosterone to estradiol.[21][22] It should be noted however that all the participants in this study were referred after infertility was discovered or highly suspected and conclusion made is purely conjecture. No specific gene has been identified. research to date suggests that insulin resistance could be a leading cause. These "cysts" are actually immature follicles. A majority of patients with PCOS have insulin resistance and/or are obese. particularly testosterone. Leventhal. The excess of adipose tissue in obese patients creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and estrogens (which inhibits FSH via negative feedback). and the cause cannot be determined for all patients. but the development has stopped ("arrested") at an early antral stage due to the disturbed ovarian function. The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts.[19][20] One study in the United Kingdom concluded that the risk of PCOS development was shown to be higher in lesbian women than in heterosexuals. PCOS may also have a genetic predisposition. The follicles may be oriented along the ovarian periphery. appearing as a 'string of pearls' on ultrasound examination. PCOS may be associated with chronic inflammation. and decreased SHBG binding. The follicles have developed from primordial follicles. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. and it is thought that many genes could contribute to the development of PCOS. Insulin resistance is a common finding among patients of normal weight as well as those overweight patients.[edit] Pathogenesis Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens).

Ovulation may be predicted by the use of urine tests that detect the . Low-carbohydrate diets and sustained regular exercise may help. Broadly.[edit] Management Medical treatment of PCOS is tailored to the patient's goals. and prevention of endometrial hyperplasia and endometrial cancer In each of these areas. vegetables and whole grain sources. have been an obvious approach and initial studies seemed to show effectiveness. these may be considered under four categories: y y y y Lowering of insulin levels Restoration of fertility Treatment of hirsutism or acne Restoration of regular menstruation. One of the major reasons for this is the lack of large scale clinical trials comparing different treatments. restore ovulation and fertility. Regular exercise and maintaining a healthy weight will help reduce the hormonal imbalance. and improve acne and hirsutism. and the newer thiazolidinedione (glitazones). because they address what is believed to be the underlying cause of the syndrome. anovulation is a common cause. the United Kingdom's National Institute for Health and Clinical Excellence recommended in 2004 that women with PCOS and a body mass index above 25 be given metformin when other therapy has failed to produce results. but many women find it very difficult to achieve and sustain significant weight loss. Some experts recommend a low GI diet in which a significant part of total carbohydrates are obtained from fruit. General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims.[24] [edit] Medications Reducing insulin resistance by improving insulin sensitivity through medications such as metformin. Smaller trials tend to be less reliable and hence may produce conflicting results. For those who do.[23] [edit] Insulin lowering [edit] Diet Where PCOS is associated with overweight or obesity. successful weight loss is probably the most effective method of restoring normal ovulation/menstruation.[26] However subsequent reviews in 2008 and 2009 have noted that randomised control trials have in general not shown the promise suggested by the early observational studies.[27][28] [edit] Infertility Not all women with PCOS have difficulty becoming pregnant. there is considerable debate as to the optimal treatment.[25] Although metformin is not licensed for use in PCOS.

these were women with significant fertility problems. The live-birth rates following 6 months of treatment were 7.[31] In this trial. However.5% (clomiphene). Methods that predict ovulation may be used to time intercourse or insemination appropriately. For overweight women with PCOS.preovulatory LH surge. Ovulation may also be confirmed by testing for serum progesterone in mid-luteal phase. prior to IVF. 6% and 3. affecting 0%. 22. there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with FSH injections and in vitro fertilisation (IVF). The overall success rates for live birth remained disappointing. and over half had received previous treatment for infertility.2% (metformin). Thus. For those who after weightloss still are anovulatory or for anovulatory lean women. clomiphene alone. comparing clomiphene with metformin. . Following this study. This technique is known as In vitro maturation (IVM).[30] basal body temperatures may be used to confirm ovulation. or both. but it is important to consider that the women in this trial had already been attempting to conceive for an average of 3. or certain fertility monitors (those that track urinary hormones or changes in saliva) may be used. even in women receiving combined therapy. While not useful for predicting ovulation. But in the largest trial to date. and the live-birth rates are probably not representative of the typical PCOS woman. called ovulation predictor kits (OPKs). Ovarian stimulation with FSH followed by hCG has an associated risk in women with PCOS of ovarian hyperstimulation syndrome ² an uncomfortable and potentially dangerous condition with morbidity and rare mortality. Previously.[29] Charting of cervical mucus may also be used to predict ovulation.[34] It is currently unknown if diet change and weight loss alone have an effect on live birth rates comparable to those reported with clomiphene and metformin For patients who do not respond to clomiphene. and 26. weight loss. approximately seven days after ovulation (if ovulation occurred on the average cycle day of fourteen.5 years. the ESHRE/ASRMsponsored Consensus workshop do not recommend metformin for ovulation stimulation. A mid-luteal phase progesterone test may also be used to diagnose luteal phase defect. even metformin was recommended treatment for anovulation.8% (both). clomiphene alone was the most effective. 626 women were randomized to three groups: metformin alone. Thus recent developments have allowed the oocytes present in the multiple follicles to be extracted in natural. unstimulated cycles and then matured in vitro.1% of women respectively.[32] Subsequent randomized studies have confirmed the lack of evidence for adding metformin to clomiphene.[33] The most drastic increase in ovulation rate occurs with a combination of diet modification. who are anovulatory. diet adjustments and weight loss are associated with resumption of spontaneous ovulation. clomiphene citrate and FSH are the principal treatments used to help infertility. seven days later would be cycle day 21). OPKs are not always accurate when testing on women with PCOS. diet and lifestyle modification. and treatment with metformin and clomiphene citrate. The major complication of clomiphene was multiple pregnancy. Methods that confirm ovulation may be used to evaluate the effectiveness of treatments to stimulate ovulation.

The RCOG (The Royal College of Obstetricians and Gynaecologists) has recently published an opinion paper on "Metformin therapy for the management of women with polycystic ovary syndrome". and should be restricted to those patients with glucose intolerance or type 2 diabetes rather than those with just insulin resistance. in women of child-bearing age who require contraception). and acts directly on the hair follicles to inhibit hair growth. perhaps by reducing insulin resistance. the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (puncture of 4-10 small follicles with electrocautery). Other drugs with anti-androgen effects include flutamide and spironolactone.g. which often results in either resumption of spontaneous ovulations or ovulations after adjuvant treatment with clomiphene or FSH. The European Society for Human Reproduction and Embryology and American Society for Reproductive Medicine consensus on infertility treatment for PCOS concluded that there is no clear role for insulin sensitising and insulin lowering drugs in the management of PCOS. A common choice of contraceptive pill is one that contains cyproterone acetate. but drug treatments do not work well for all individuals. Cyproterone acetate is a progestogen with anti-androgen effects that blocks the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair. or the inconvenience of plucking/shaving. which may not be enough to eliminate the social embarrassment of hirsutism. Spironolactone is probably the most-commonly used drug in the US. . Metformin can reduce hirsutism. Eflornithine (Vaniqa) is a drug which is applied to the skin in cream form. [edit] Hirsutism and acne When appropriate (e. Medications that reduce acne by indirect hormonal effects also include ergot dopamine agonists such as bromocriptine. The paper concluded that while initial studies appeared to be promising. in the UK/US the available brands are Dianette/Diane. and is often used if there are other features such as insulin resistance. and it is usually worth trying other drug treatments if one does not work. the average reduction in hair growth is generally in the region of 25%. Therefore. electrolysis or laser treatments are faster and more efficient alternatives than the above mentioned medical therapies. It is usually applied to the face. Most work has been undertaken in the management of anovulatory infertility and there are no good data from randomised controlled trials on the use of metformin in the management of other manifestations of PCOS. a standard contraceptive pill may be effective in reducing hirsutism. It is clear that the first aim for women with PCOS who are overweight is to make lifestyle changes with a combination of diet and exercise in order to lose weight and improve ovarian function. more recent large randomised controlled trials have not observed beneficial effects of metformin either as first-line therapy or combined with clomifene citrate for the treatment of the anovulatory woman with PCOS. diabetes or obesity that should also benefit from metformin. on current evidence metformin is not a first line treatment of choice in the management of PCOS(RCOG December 2008)[1] Though surgery is not commonly performed. some improvement in hirsutism. Individuals may vary in their response to different therapies. Although all of these agents have shown some efficacy in clinical trials. For removal of facial hairs.

then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer. If a regular menstrual cycle is not desired. and perhaps her sense of well-being.[37] DCI is regulated as a dietary supplement in the United States. then therapy for an irregular cycle is not necessarily required . double-blind studies and found to help both lean and obese women with PCOS. [edit] Alternative approaches D-chiro-inositol (DCI) offers a well-tolerated and effective alternative treatment for PCOS. though the effects are caused by substituted hormones that can easily cause more problems if the pill is taken for a long period of time. which provides simultaneous contraception and endometrial protection for years. If menstruation occurs less often or not at all. diminishing many of the primary clinical presentations of PCOS. then menstruation can usually be regulated with a contraceptive pill.[edit] Menstrual irregularity and endometrial hyperplasia If fertility is not the primary aim.g.most experts consider that if a menstrual bleed occurs at least every three months. every three months) to induce a predictable menstrual bleeding. The purpose of regulating menstruation is essentially for the woman's convenience. Some women prefer a uterine progestogen device such as the intrauterine system (Mirena) or the progestin implant (Implanon). . An alternative is oral progestogen taken at intervals (e. so long as they occur sufficiently often (see below). there is no medical requirement for regular periods. some form of progestogen replacement is recommended.[35][36] It has no documented side-effects and is a naturally occurring human metabolite known to be involved in insulin metabolism. It has been evaluated in two peer-reviewed.

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