Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS), also called hyperandrogenic anovulation (HA),[1] or Stein-Leventhal
syndrome,[2] is one of the most common endocrine disorders among females. PCOS has a diverse range of
causes that are not entirely understood, but there is strong evidence that it is largely a genetic disease.[3][4][5]

PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (approximately 12 to

45 years old). It is thought to be one of the leading causes of female subfertility[6][7][8] and the most frequent
endocrine problem in women of reproductive age.[9] Finding that the ovaries appear polycystic on ultrasound
is common, but it is not an absolute requirement in all definitions of the disorder.

The most common immediate symptoms are anovulation, excess androgenic hormones, and insulin resistance.
Anovulation results in irregular menstruation, amenorrhea, and ovulation-related infertility. Hormone
imbalance generally causes acne and hirsutism. Insulin resistance is associated with obesity, Type 2 diabetes,
and high cholesterol levels.[10] The symptoms and severity of the syndrome vary greatly among affected
women.

Signs and symptoms

Common symptoms of PCOS include the following:

 Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea
(no menstrual periods), but other types of menstrual disorders may also occur.[9][11]
 Infertility:[11] This generally results directly from chronic anovulation (lack of ovulation).[9]
 High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern
of hair growth), but it may produce hypermenorrhea (heavy and prolonged menstrual periods),
androgenic alopecia (increase hair thining or diffuse hair loss), or other symptoms.[9][12] Approximately
three-quarters of people with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of
hyperandrogenemia.[13]
 Metabolic syndrome:[11] This appears as a tendency towards central obesity and other symptoms
associated with insulin resistance.[9] Serum insulin, insulin resistance, and homocysteine levels are
higher in women with PCOS.[14]

When Asian women are affected with PCOS, they are less likely to develop hirsutism than women of other
ethnic backgrounds.[15]

Cause

PCOS is a heterogeneous disorder of uncertain cause.[3][4][11] There is strong evidence that it is a genetic
disease. Such evidence includes the familial clustering of cases, greater concordance in monozygotic
compared with dizygotic twins and heritability of endocrine and metabolic features of PCOS.[3][4][5]

The genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance
but variable expressivity in females; this means that each child has a 50% chance of inheriting the predisposing
genetic variant(s) from a parent, and, if a daughter receives the variant(s), the daughter will have the disease
to some extent.[4][16][17][18] The genetic variant(s) can be inherited from either the father or the mother, and can
be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early baldness
and/or excessive hair) and daughters, who will show signs of PCOS.[16][18] The allele appears to manifest itself
at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the
allele.[17] The exact gene affected has not yet been identified.[4][5][19]

The clinical severity of PCOS symptoms appears to be largely determined by factors such as obesity.[5][9]

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Diagnosis

Not all women with PCOS have polycystic ovaries (PCO), nor do all women with ovarian cysts have PCOS;
although a pelvic ultrasound is a major diagnostic tool, it is not the only one.[20] The diagnosis is
straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of
symptoms.

Polycystic Ovary as seen Transvaginal ultrasound Polycystic Ovary as

on Sonography scan of polycystic ovary seen on Sonography

Definition

Two definitions are commonly used:

NIH

In 1990 a consensus workshop sponsored by the NIH/NICHD suggested that a person has PCOS if she has all
of the following:[21]

1. oligoovulation
2. signs of androgen excess (clinical or biochemical)
3. exclusion of other disorders that can result in menstrual irregularity and hyperandrogenism

Rotterdam

In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if

any 2 out of 3 criteria are met[22]

1. oligoovulation and/or anovulation

2. excess androgen activity
3. polycystic ovaries (by gynecologic ultrasound)
4. Other entities are excluded that would cause these.[9][23]

The Rotterdam definition is wider, including many more women, the most notable ones being women without
androgen excess. Critics say that findings obtained from the study of women with androgen excess cannot
necessarily be extrapolated to women without androgen excess.[24][25]

Androgen Excess PCOS Society

In 2006, the Androgen Excess PCOS Society suggested a tightening of the diagnostic criteria to all of:[9]

1. excess androgen activity

2. oligoovulation/anovulation and/or polycystic ovaries
3. exclusion of other entities that would cause excess androgen activity

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Standard diagnostic assessments

 History-taking, specifically for menstrual pattern, obesity, hirsutism, and the absence of breast
development. A clinical prediction rule found that these four questions can diagnose PCOS with a
sensitivity of 77.1% (95% confidence interval [CI] 62.7%–88.0%) and a specificity of 93.8% (95% CI
82.8%–98.7%).[26]
 Gynecologic ultrasonography, specifically looking for small ovarian follicles. These are believed to
be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent
menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a
dominant follicle – in essence, a cyst that bursts to release the egg. After ovulation, the follicle remnant
is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after
approximately 12–14 days. In PCOS, there is a so-called "follicular arrest"; i.e., several follicles
develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm
or more). According to the Rotterdam criteria, 12 or more small follicles should be seen in an ovary
on ultrasound examination.[21] More recent research suggests that there should be at least 25 follicles
in an ovary to designate it as having polycystic ovarian morphology (PCOM) in women aged 18–35
years.[27] The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'. If
a high resolution transvaginal ultrasonography machine is not available, an ovarian volume of at least
10 ml is regarded as an acceptable definition of having polycystic ovarian morphology instead of
follicle count.[27]
 Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary.
(This would usually be an incidental finding if laparoscopy were performed for some other reason, as
it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)[citation needed]
 Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may
be elevated.[9] Dehydroepiandrosterone sulfate levels above 700-800 µg/dL are highly suggestive of
adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands.[28][29] The free
testosterone level is thought to be the best measure,[29][30] with ~60% of PCOS patients demonstrating
supranormal levels.[13] The Free androgen index (FAI) of the ratio of testosterone to sex hormone-
binding globulin (SHBG) is high[9][29] and is meant to be a predictor of free testosterone, but is a poor
parameter for this and is no better than testosterone alone as a marker for PCOS,[31] possibly because
FAI is correlated with the degree of obesity.[32]

Some other blood tests are suggestive but not diagnostic. The ratio of LH (Luteinizing hormone) to FSH
(Follicle-stimulating hormone), when measured in international units, is elevated in women with PCOS.
Common cut-offs to designate abnormally high LH/FSH ratios are 2:1[33] or 3:1[29] as tested on Day 3 of the
menstrual cycle. The pattern is not very specific and a ratio of 2:1 or higher was present in less than 50% of
women with PCOS in one study.[33] There are often low levels of sex hormone-binding globulin,[29] in
particular among obese or overweight women.[citation needed]

Anti-Müllerian hormone (AMH) is increased in PCOS, and may become part of its diagnostic criteria.[34]

Associated conditions

 Fasting biochemical screen and lipid profile[29]

 2-Hour oral glucose tolerance test (GTT) in women with risk factors (obesity, family history, history
of gestational diabetes)[9] may indicate impaired glucose tolerance (insulin resistance) in 15–33% of
women with PCOS.[29] Frank diabetes can be seen in 65–68% of women with this condition.[citation
needed] Insulin resistance can be observed in both normal weight and overweight people, although it is

more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of
people with PCOS may have insulin resistance at some level.[9]
 Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been
helpful to predict response to medication and may indicate women needing 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, low-glycemic diet,
August 23, 2014 @shrabonbd™ 3|Page
 and exercise. Many women with normal levels may benefit from combination 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. A mathematical derivation known as the HOMAI,
calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately
accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).[citation needed]
 Glucose tolerance testing (GTT) instead of fasting glucose can increase diagnosis of increased glucose
tolerance and frank diabetes among people with PCOS according to a prospective controlled trial.[35]
While fasting glucose levels may remain within normal limits, oral glucose tests revealed that up to
38% of asymptomatic women with PCOS (versus 8.5% in the general population) actually had
impaired glucose tolerance, 7.5% of those with frank diabetes according to ADA guidelines.[35]

Differential diagnosis

Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal
hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secreting
neoplasms, and other pituitary or adrenal disorders, should be investigated.[9][23][29] PCOS has been reported
in other insulin-resistant situations such as acromegaly.[citation needed]

Pathogenesis

Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones
(androgens), in particular testosterone, by either one or a combination of the following (almost certainly
combined with genetic susceptibility[17]):

 the release of excessive luteinizing hormone (LH) by the anterior pituitary gland[citation needed]
 through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive
to this stimulus[11]

Also, reduced levels of sex-hormone-binding globulin can result in increased free androgens.[citation needed]

The syndrome acquired its most widely used name due to the common sign on ultrasound examination of
multiple (poly) ovarian cysts. These "cysts" are actually immature follicles not cysts. The follicles have
developed from primordial follicles, but the development has stopped ("arrested") at an early antral stage due
to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a
'string of pearls' on ultrasound examination.[citation needed]

Women with PCOS experience an increased frequency of hypothalamic GnRH pulses, which in turn results
in an increase in the LH/FSH ratio.[36]

A majority of people with PCOS have insulin resistance and/or are obese. Their elevated insulin levels
contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS.
Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen
production,[11] decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the
development of PCOS.[citation needed] Insulin resistance is a common finding among women with a normal weight
as well as overweight women.[9][14]

In many cases, PCOS is characterised by a complex positive feedback loop of insulin resistance and
hyperandrogenism. In most cases, it cannot be determined which (if any) of those two should be regarded
causative. Experimental treatment with either antiandrogens or insulin-sensitizing agents improves both
hyperandrogenism and insulin resistance.[citation needed]

Adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to
estradiol. The excess of adipose tissue in obese women creates the paradox of having both excess androgens

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(which are responsible for hirsutism and virilization) and estrogens (which inhibits FSH via negative
feedback).[37]

PCOS may be associated with chronic inflammation,[11][38] with several investigators correlating inflammatory
mediators with anovulation and other PCOS symptoms.[39][40] Similarly, there seems to be a relation between
PCOS and increased level of oxidative stress.[41]

It has previously been suggested that the excessive androgen production in PCOS could be caused by a
decreased serum level of IGFBP-1, in turn increasing the level of free IGF-I, which stimulates ovarian
androgen production, but recent data concludes this mechanism to be unlikely.[42]

PCOS has also been associated with a specific FMR1 sub-genotype. The research suggests that women with
heterozygous-normal/low FMR1 have polycystic-like symptoms of excessive follicle-activity and hyperactive
ovarian function.[43]

Management

Medical treatment of PCOS is tailored to the woman's goals. In broad terms, these may be considered under
four categories:

 Lowering of insulin resistance levels

 Restoration of fertility
 Treatment of hirsutism or acne
 Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer

In each of these areas, there is considerable debate as to the optimal treatment. One of the major reasons for
this is the lack of large-scale clinical trials comparing different treatments. Smaller trials tend to be less reliable
and hence may produce conflicting results.

General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims,
because they address what is believed to be the underlying cause.

As PCOS appears to cause significant emotional distress, appropriate support may be useful.[44]

Diet

Where PCOS is associated with overweight or obesity, successful weight loss is the most effective method of
restoring normal ovulation/menstruation, but many women find it very difficult to achieve and sustain
significant weight loss. A scientific review in 2013 found similar decreases in weight and body composition
and improvements in pregnancy rate, menstrual regularity, ovulation, hyperandrogenism, insulin resistance,
lipids, and quality of life to occur with weight loss independent of diet composition.[45] Still, a low GI diet, in
which a significant part of total carbohydrates are obtained from fruit, vegetables, and whole-grain sources,
has resulted in greater menstrual regularity than a macronutrient-matched healthy diet.[45] Vitamin D
deficiency may play some role in the development of the metabolic syndrome, so treatment of any such
deficiency is indicated.[46]

Medications

Reducing insulin resistance by improving insulin sensitivity through medications such as metformin, and the
newer thiazolidinedione (glitazones), have been an obvious approach and initial studies seemed to show
effectiveness.[11][46][47] Although metformin is not licensed for use in PCOS, 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.[48] However subsequent

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reviews in 2008 and 2009 have noted that randomised control trials have in general not shown the promise
suggested by the early observational studies.[49][50]

Infertility

Not all women with PCOS have difficulty becoming pregnant. For those that do, anovulation or infrequent
ovulation is a common cause. Other factors include changed levels of gonadotropins, hyperandrogenemia and
hyperinsulinemia.[51] Like women without PCOS, women with PCOS that are ovulating may be infertile due
to other causes, such as tubal blockages due to a history of sexually transmitted diseases.

For overweight, anovulatory women with PCOS, weight loss and diet adjustments, especially to reduce the
intake of simple carbohydrates, are associated with resumption of natural ovulation.

For those women that after weight loss still are anovulatory or for anovulatory lean women, then the ovulation-
inducing medications clomiphene citrate[46] and FSH are the principal treatments used to promote ovulation.[11]
Previously, the anti-diabetes medication metformin was recommended treatment for anovulation,[11] but it
appears less effective than clomiphene.[52]

For women not responsive to clomiphene and diet and lifestyle modification, there are options available
including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with
follicle-stimulating hormone (FSH) injections followed by in vitro fertilisation (IVF).

Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic
procedure called "ovarian drilling" (puncture of 4–10 small follicles with electrocautery, laser, or biopsy
needles), which often results in either resumption of spontaneous ovulations[46] or ovulations after adjuvant
treatment with clomiphene or FSH.[citation needed] (Ovarian wedge resection is no longer used as much due to
complications such as adhesions and the presence of frequently effective medications.) There are, however,
concerns about the long-term effects of ovarian drilling on ovarian function.[46]

Hirsutism and acne

For more details on this topic, see Hirsutism.

When appropriate (e.g., in women of child-bearing age who require contraception), a standard contraceptive
pill is frequently effective in reducing hirsutism.[11][46] A common choice of contraceptive pill is one that
contains cyproterone acetate; in the UK, the available brands are Dianette/Diane. Cyproterone acetate is a
progestogen with anti-androgen effects that block the action of male hormones that are believed to contribute
to acne and the growth of unwanted facial and body hair.[citation needed] On the other hand, progestogens such as
norgestrel and levonorgestrel should be avoided due to their androgenic effects.[46]

Other drugs with anti-androgen effects include flutamide,[53] and spironolactone,[11][46] which can give some
improvement in hirsutism. Spironolactone is probably the most-commonly used drug in the US. Metformin
can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such
as insulin resistance, diabetes, or obesity that should also benefit from metformin. Eflornithine (Vaniqa) is a
drug that is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is
usually applied to the face.[46] Medications that reduce acne by indirect hormonal effects also include ergot
dopamine agonists such as bromocriptine.[citation needed] 5-alpha reductase inhibitors (such as finasteride and
dutasteride) may also be used;[54] they work by blocking the conversion of testosterone to dihydrotestosterone
(the latter of which responsible for most hair growth alterations and androgenic acne).

Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100%
of individuals[46]), the reduction in hair growth may not be enough to eliminate the social embarrassment of
hirsutism, or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies.
It is usually worth trying other drug treatments if one does not work, but drug treatments do not work well for
August 23, 2014 @shrabonbd™ 6|Page
all individuals. For removal of facial hairs, electrolysis, or laser treatments are – at least for some – faster and
more efficient alternatives than the above mentioned medical therapies.[citation needed]

Menstrual irregularity and endometrial hyperplasia

If fertility is not the primary aim, then menstruation can usually be regulated with a contraceptive pill.[11][46]
The purpose of regulating menstruation, in essence, is for the woman's convenience, and perhaps her sense of
well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often.

If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most
experts say that, if a menstrual bleed occurs at least every three months, then the endometrium (womb lining)
is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.[55] If
menstruation occurs less often or not at all, some form of progestogen replacement is recommended.[54] An
alternative is oral progestogen taken at intervals (e.g., every three months) to induce a predictable menstrual
bleeding.[11]

Alternative medicine

There is insufficient evidence to conclude an effect from D-chiro-inositol.[56] Myo-inositol however appears
to be effective based on a systematic review.[57]

Prognosis

Women with PCOS are at risk for the following:

 Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to
overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of
uterine cells by estrogen.[11][21] It is not clear whether this risk is directly due to the syndrome or from
the associated obesity, hyperinsulinemia, and hyperandrogenism.[58][59][60][61]
 Insulin resistance/Type II diabetes.[11] A review published in 2010 concluded that women with PCOS
have an elevated prevalence of insulin resistance and type II diabetes, even when controlling for body
mass index (BMI).[21][62] PCOS also makes a woman, particularly if obese, prone to gestational
diabetes.[11]
 High blood pressure, in particular if obese and/or during pregnancy[11]
 Depression/Depression with Anxiety[9][63]
 Dyslipidemia[11] – disorders of lipid metabolism — cholesterol and triglycerides. Women with PCOS
show a decreased removal of atherosclerosis-inducing remnants, seemingly independent of insulin
resistance/Type II diabetes.[64]
 Cardiovascular disease,[11][21] with a meta-analysis estimating a 2-fold risk of arterial disease for
women with PCOS relative to women without PCOS, independent of BMI.[65]
 Strokes[21]
 Weight gain[11]
 Miscarriage[6][7]
 Sleep apnea, particularly if obesity is present[11]
 Non-alcoholic fatty liver disease, again particularly if obesity is present[11]
 Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the
neck)[21]
 Autoimmune thyroiditis[66]

Early diagnosis and treatment may reduce the risk of some of these, such as type 2 diabetes and heart
disease.[11]

Epidemiology

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The prevalence of PCOS depends on the choice of diagnostic criteria. The World Health Organization
estimates that it affects 116 million women worldwide as of 2010 (3.4% of women).[67] One community-based
prevalence study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of
them were previously undiagnosed.[9]

One study in the United Kingdom concluded that the risk of PCOS development was higher in lesbian women
than in heterosexuals.[68] However, two subsequent studies of women with PCOS have not replicated this
finding.[69][70] Ultrasonographic findings of polycystic ovaries are found in 8-25% of normal
women.[71][72][73][74] 14% women on oral contraceptives are found to have polycystic ovaries.[72]

History

The condition was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L.
Leventhal, from whom its original name of Stein-Leventhal syndrome is taken.[20][21]

The earliest published description of a person with what is now recognized as PCOS was in 1721 in Italy.[75]
Cyst-related changes to the ovaries were described in 1844.[75]

Names

Other names for this syndrome include polycystic ovary disease, functional ovarian hyperandrogenism,
ovarian hyperthecosis, sclerocystic ovary syndrome, and Stein-Leventhal syndrome. The eponymous last
option is the original name; it is now used, if at all, only for the subset of women with all the symptoms of
amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries.[20]

Most common names for this disease derive from a typical finding on medical images, called a polycystic
ovary.[11] A polycystic ovary has an abnormally large number of developing eggs visible near its surface,[20]
looking like many small cysts[76] or a string of pearls.
©Wikipedia, the free encyclopedia

Polycystic Ovary Syndrome (PCOS) - Treatment Overview

Regular exercise, a healthy diet, weight control, and not smoking are all important parts of treatment for
polycystic ovary syndrome (PCOS). You may also take medicine to balance your hormones.
August 23, 2014 @shrabonbd™ 8|Page
Treatments depend on your symptoms and whether you are planning a pregnancy.

Recommended Related to Women

From its first year of publication, GH has urged readers to live healthfully — to take "a walk before breakfast"
(1885), "eat more fish" (1932), and get "at least eight hours of sleep" (1933). The tips here, whether from our
early days or fresh from the latest journals, have one thing in common: They are based on the best expertise
of their time.

There is no cure for PCOS, but controlling it lowers your risks of infertility, miscarriages, diabetes, heart
disease, and uterine cancer.

Healthy lifestyle

 If you are overweight, weight loss may be all the treatment you need. A small amount of
weight loss is likely to help balance your hormones and start up your menstrual cycle and
ovulation.
 Eat a balanced diet that includes lots of fruits, vegetables, whole grains, and low-fat dairy
products.
 Get regular exercise to help you control or lose weight and feel better.
 If you smoke, consider quitting. Women who smoke have higher levels of androgens than
women who don't smoke.1

Hormone therapy

If weight loss alone doesn't start ovulation (or if you don't need to lose weight), your doctor may have you try
a medicine such as metformin or clomiphene to help you start to ovulate.

If you aren't planning a pregnancy, you can also use hormone therapy to help control your ovary hormones.
To correct menstrual cycle problems, birth control hormones keep your endometrial lining from building up
for too long. This can prevent uterine cancer.

Hormone therapy also can help with male-type hair growth and acne. Birth control pills, patches, or vaginal
rings are prescribed for hormone therapy. Androgen-lowering spironolactone (Aldactone) is often used with
combined hormonal birth control. This helps with hair loss, acne, and male-pattern hair growth on the face
and body (hirsutism).

Taking hormones doesn't help with heart, blood pressure, cholesterol, and diabetes risks. This is why exercise
and a healthy diet are key parts of your treatment.

If weight loss and medicine don't restart ovulation, you may want to try other treatments. For more
information, see the topic Fertility Problems.

Regular checkups

Regular checkups are important for catching any PCOS complications, such as high blood pressure, high
cholesterol, uterine cancer, heart disease, and diabetes.

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a common hormonal disorder among women of reproductive age. The
name of the condition comes from the appearance of the ovaries in most, but not all, women with the disorder

August 23, 2014 @shrabonbd™ 9|Page

— enlarged and containing numerous small cysts located along the outer edge of each ovary (polycystic
appearance).

Infrequent or prolonged menstrual periods, excess hair growth, acne and obesity can all occur in women with
polycystic ovary syndrome. In adolescents, infrequent or absent menstruation may signal the condition. In
women past adolescence, difficulty becoming pregnant or unexplained weight gain may be the first sign.

The exact cause of polycystic ovary syndrome is unknown. Early diagnosis and treatment may reduce the risk
of long-term complications, such as type 2 diabetes and heart disease.

Polycystic ovary syndrome is a disorder involving infrequent or prolonged menstrual periods or excess male
hormone (androgen) levels. The ovaries develop numerous small cysts and may fail to release eggs.

Polycystic (pah-lee-SIS-tik) ovary syndrome (PCOS) is a health problem that can affect a woman's:

 Menstrual cycle
 Ability to have children
 Hormones
 Heart
 Blood vessels
 Appearance

With PCOS, women typically have:

 High levels of androgens (AN-druh-junz). These are sometimes called male hormones, though females
also make them.
 Missed or irregular periods (monthly bleeding)
 Many small cysts (sists) (fluid-filled sacs) in their ovaries

How many women have PCOS?

Between 1 in 10 and 1 in 20 women of childbearing age has PCOS. As many as 5 million women in the United
States may be affected. It can occur in girls as young as 11 years old.

August 23, 2014 @shrabonbd™ 10 | P a g e

What causes PCOS?
The cause of PCOS is unknown. But most experts think that several factors, including genetics, could play a
role. Women with PCOS are more likely to have a mother or sister with PCOS.

A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make
more androgens than normal. Androgens are male hormones that females also make. High levels of these
hormones affect the development and release of eggs during ovulation.

Researchers also think insulin may be linked to PCOS. Insulin is a hormone that controls the change of sugar,
starches, and other food into energy for the body to use or store. Many women with PCOS have too much
insulin in their bodies because they have problems using it. Excess insulin appears to increase production of
androgen. High androgen levels can lead to:

 Acne
 Excessive hair growth
 Weight gain
 Problems with ovulation

What are the symptoms of PCOS?

The symptoms of PCOS can vary from woman to woman. Some of the symptoms of PCOS include:

 Infertility (not able to get pregnant) because of not ovulating. In fact, PCOS is the most common cause of
female infertility.
 Infrequent, absent, and/or irregular menstrual periods
 Hirsutism (HER-suh-tiz-um) — increased hair growth on the face, chest, stomach, back, thumbs, or toes
 Cysts on the ovaries
 Acne, oily skin, or dandruff
 Weight gain or obesity, usually with extra weight around the waist
 Male-pattern baldness or thinning hair
 Patches of skin on the neck, arms, breasts, or thighs that are thick and dark brown or black
 Skin tags — excess flaps of skin in the armpits or neck area
 Pelvic pain
 Anxiety or depression
 Sleep apnea — when breathing stops for short periods of time while asleep

Why do women with PCOS have trouble with their menstrual cycle
and fertility?
The ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs called follicles or cysts. As the
egg grows, the follicle builds up fluid. When the egg matures, the follicle breaks open, the egg is released, and
the egg travels through the fallopian tube to the uterus (womb) for fertilization. This is called ovulation.

In women with PCOS, the ovary doesn't make all of the hormones it needs for an egg to fully mature. The
follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain
as cysts. For these reasons, ovulation does not occur and the hormone progesterone is not made. Without
progesterone, a woman's menstrual cycle is irregular or absent. Plus, the ovaries make male hormones, which
also prevent ovulation.

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 Normal ovary and polycystic ovary

Does PCOS change at menopause?

Yes and no. PCOS affects many systems in the body. So, many symptoms may persist even though ovarian
function and hormone levels change as a woman nears menopause. For instance, excessive hair growth
continues, and male-pattern baldness or thinning hair gets worse after menopause. Also, the risks of
complications (health problems) from PCOS, such as heart attack, stroke, and diabetes, increase as a woman
gets older.

How do I know if I have PCOS?

There is no single test to diagnose PCOS. Your doctor will take the following steps to find out if you have
PCOS or if something else is causing your symptoms.

Medical history. Your doctor will ask about your menstrual periods, weight changes, and other symptoms.

Physical exam. Your doctor will want to measure your blood pressure, body mass index (BMI), and waist
size. He or she also will check the areas of increased hair growth. You should try to allow the natural hair to
grow for a few days before the visit.

Pelvic exam. Your doctor might want to check to see if your ovaries are enlarged or swollen by the increased
number of small cysts.

Blood tests. Your doctor may check the androgen hormone and glucose (sugar) levels in your blood.

Vaginal ultrasound (sonogram). Your doctor may perform a test that uses sound waves to take pictures of
the pelvic area. It might be used to examine your ovaries for cysts and check the endometrium (en-do-MEE-
tree-uhm) (lining of the womb). This lining may become thicker if your periods are not regular.

How is PCOS treated?

Because there is no cure for PCOS, it needs to be managed to prevent problems. Treatment goals are based on
your symptoms, whether or not you want to become pregnant, and lowering your chances of getting heart

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disease and diabetes. Many women will need a combination of treatments to meet these goals. Some treatments
for PCOS include:

Lifestyle modification. Many women with PCOS are overweight or obese, which can cause health problems.
You can help manage your PCOS by eating healthy and exercising to keep your weight at a healthy level.
Healthy eating tips include:

 Limiting processed foods and foods with added sugars

 Adding more whole-grain products, fruits, vegetables, and lean meats to your diet

This helps to lower blood glucose (sugar) levels, improve the body's use of insulin, and normalize hormone
levels in your body. Even a 10 percent loss in body weight can restore a normal period and make your cycle
more regular.

Birth control pills. For women who don't want to get pregnant, birth control pills can:
 Control menstrual cycles
 Reduce male hormone levels
 Help to clear acne

Keep in mind that the menstrual cycle will become abnormal again if the pill is stopped. Women may also
think about taking a pill that only has progesterone (proh-JES-tuh-rohn), like Provera, to control the menstrual
cycle and reduce the risk of endometrial cancer (See Does PCOS put women at risk for other health
problems?). But, progesterone alone does not help reduce acne and hair growth.

Diabetes medications. The medicine metformin (Glucophage) is used to treat type 2 diabetes. It has also been
found to help with PCOS symptoms, though it isn’t approved by the U.S Food and Drug Administration (FDA)
for this use. Metformin affects the way insulin controls blood glucose (sugar) and lowers testosterone
production. It slows the growth of abnormal hair and, after a few months of use, may help ovulation to return.
Recent research has shown metformin to have other positive effects, such as decreased body mass and
improved cholesterol levels. Metformin will not cause a person to become diabetic.

Fertility medications. Lack of ovulation is usually the reason for fertility problems in women with PCOS.
Several medications that stimulate ovulation can help women with PCOS become pregnant. Even so, other
reasons for infertility in both the woman and man should be ruled out before fertility medications are used.
Also, some fertility medications increase the risk for multiple births (twins, triplets). Treatment options
include:

 Clomiphene (KLOHM-uh-feen) (Clomid, Serophene) — the first choice therapy to stimulate ovulation for most
patients.
 Metformin taken with clomiphene — may be tried if clomiphene alone fails. The combination may help women
with PCOS ovulate on lower doses of medication.
 Gonadotropins (goe-NAD-oh-troe-pins) — given as shots, but are more expensive and raise the risk of multiple
births compared to clomiphene.

Another option is in vitro fertilization (IVF). IVF offers the best chance of becoming pregnant in any given
cycle. It also gives doctors better control over the chance of multiple births. But, IVF is very costly.

Surgery. "Ovarian drilling" is a surgery that may increase the chance of ovulation. It’s sometimes used when
a woman does not respond to fertility medicines. The doctor makes a very small cut above or below the navel
(belly button) and inserts a small tool that acts like a telescope into the abdomen (stomach). This is called
laparoscopy (lap-uh-RAHS-kuh-pee). The doctor then punctures the ovary with a small needle carrying an
electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue
on the ovary. This surgery can lower male hormone levels and help with ovulation. But, these effects may

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only last a few months. This treatment doesn't help with loss of scalp hair or increased hair growth on other
parts of the body.

Medicine for increased hair growth or extra male hormones. Medicines called anti-androgens may reduce
hair growth and clear acne. Spironolactone (speer-on-oh-LAK-tone) (Aldactone), first used to treat high blood
pressure, has been shown to reduce the impact of male hormones on hair growth in women. Finasteride (fin-
AST-uhr-yd) (Propecia), a medicine taken by men for hair loss, has the same effect. Anti-androgens are often
combined with birth control pills. These medications should not be taken if you are trying to become pregnant.

Before taking Aldactone, tell your doctor if you are pregnant or plan to become pregnant. Do not breastfeed
while taking this medicine. Women who may become pregnant should not handle Propecia.

Other options include:

 Vaniqa (van-ik-uh) cream to reduce facial hair

 Laser hair removal or electrolysis to remove hair
 Hormonal treatment to keep new hair from growing

Other treatments. Some research has shown that bariatric (weight loss) surgery may be effective in resolving
PCOS in morbidly obese women. Morbid obesity means having a BMI of more than 40, or a BMI of 35 to 40
with an obesity-related disease. The drug troglitazone (troh-GLIT-uh-zohn) was shown to help women with
PCOS. But, it was taken off the market because it caused liver problems. Similar drugs without the same side
effect are being tested in small trials.

Researchers continue to search for new ways to treat PCOS. To learn more about current PCOS treatment studies, visit
ClinicalTrials.gov. Talk to your doctor about whether taking part in a clinical trial might be right for you.

How does PCOS affect a woman while pregnant?

Women with PCOS appear to have higher rates of:

 Miscarriage
 Gestational diabetes
 Pregnancy-induced high blood pressure (preeclampsia)
 Premature delivery

Babies born to women with PCOS have a higher risk of spending time in a neonatal intensive care unit or of
dying before, during, or shortly after birth. Most of the time, these problems occur in multiple-birth babies
(twins, triplets).

Researchers are studying whether the diabetes medicine metformin can prevent or reduce the chances of
having problems while pregnant. Metformin also lowers male hormone levels and limits weight gain in women
who are obese when they get pregnant.

Metformin is an FDA pregnancy category B drug. It does not appear to cause major birth defects or other
problems in pregnant women. But, there have only been a few studies of metformin use in pregnant women
to confirm its safety. Talk to your doctor about taking metformin if you are pregnant or are trying to become
pregnant. Also, metformin is passed through breastmilk. Talk with your doctor about metformin use if you
are a nursing mother.

Does PCOS put women at risk for other health problems?

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Women with PCOS have greater chances of developing several serious health conditions, including life-
threatening diseases. Recent studies found that:

 More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance)
before the age of 40.
 The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
 Women with PCOS are at greater risk of having high blood pressure.
 Women with PCOS have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol.
 Women with PCOS can develop sleep apnea. This is when breathing stops for short periods of time during
sleep.

Women with PCOS may also develop anxiety and depression. It is important to talk to your doctor about
treatment for these mental health conditions.

Women with PCOS are also at risk for endometrial cancer. Irregular menstrual periods and the lack of ovulation cause
women to produce the hormone estrogen, but not the hormone progesterone. Progesterone causes the endometrium
(lining of the womb) to shed each month as a menstrual period. Without progesterone, the endometrium becomes
thick, which can cause heavy or irregular bleeding. Over time, this can lead to endometrial hyperplasia, when the lining
grows too much, and cancer.

I have PCOS. What can I do to prevent complications?

If you have PCOS, get your symptoms under control at an earlier age to help reduce your chances of having
complications like diabetes and heart disease. Talk to your doctor about treating all your symptoms, rather
than focusing on just one aspect of your PCOS, such as problems getting pregnant. Also, talk to your doctor
about getting tested for diabetes regularly. Other steps you can take to lower your chances of health problems
include:

 Eating right
 Exercising
 Not smoking

How can I cope with the emotional effects of PCOS?

Having PCOS can be difficult. You may feel:

 Embarrassed by your appearance

 Worried about being able to get pregnant
 Depressed

Getting treatment for PCOS can help with these concerns and help boost your self-esteem. You may also want
to look for support groups in your area or online to help you deal with the emotional effects of PCOS. You
are not alone and there are resources available for women with PCOS.

Polycystic Ovary Syndrome (PCOS) - Topic Overview

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Polycystic ovary syndrome (say "pah-lee-SIS-tik OH-vuh-ree SIN-drohm") is a problem in which a woman's
hormones are out of balance. It can cause problems with your periods and make it difficult to get pregnant.
PCOS also may cause unwanted changes in the way you look. If it isn't treated, over time it can lead to serious
health problems, such as diabetes and heart disease.

Most women with PCOS grow many small cysts on their ovaries. That is why it is called polycystic ovary
syndrome. The cysts are not harmful but lead to hormone imbalances.

Early diagnosis and treatment can help control the symptoms and prevent long-term problems.

Hormones are chemical messengers that trigger many different processes, including growth and energy
production. Often, the job of one hormone is to signal the release of another hormone.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change
triggers another, which changes another. For example:

 The sex hormones get out of balance. Normally, the ovaries make a tiny amount of male sex hormones
(androgens). In PCOS, they start making slightly more androgens. This may cause you to stop
ovulating, get acne, and grow extra facial and body hair.
 The body may have a problem using insulin, called insulin resistance. When the body doesn't use
insulin well, blood sugar levels go up. Over time, this increases your chance of getting diabetes.

The cause of PCOS is not fully understood, but genetics may be a factor. PCOS seems to run in families, so
your chance of having it is higher if other women in your family have it or have irregular periods or diabetes.
PCOS can be passed down from either your mother's or father's side.

Symptoms tend to be mild at first. You may have only a few symptoms or a lot of them. The most common
symptoms are:

 Acne.
 Weight gain and trouble losing weight.
 Extra hair on the face and body. Often women get thicker and darker facial hair and more hair on the
chest, belly, and back.
 Thinning hair on the scalp.
 Irregular periods. Often women with PCOS have fewer than nine periods a year. Some women have
no periods. Others have very heavy bleeding.
 Fertility problems. Many women who have PCOS have trouble getting pregnant (infertility).
 Depression.

To diagnose PCOS, the doctor will:

 Ask questions about your past health, symptoms, and menstrual cycles.
 Do a physical exam to look for signs of PCOS, such as extra body hair and high blood pressure. The
doctor will also check your height and weight to see if you have a healthy body mass index (BMI).
 Do a number of lab tests to check your blood sugar, insulin, and other hormone levels. Hormone tests
can help rule out thyroid or other gland problems that could cause similar symptoms.

You may also have a pelvic ultrasound to look for cysts on your ovaries. Your doctor may be able to tell you
that you have PCOS without an ultrasound, but this test will help him or her rule out other problems.

Regular exercise, healthy foods, and weight control are the key treatments for PCOS. Treatment can reduce
unpleasant symptoms and help prevent long-term health problems.

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  Try to fit in moderate activity and/or vigorous activity often. Walking is a great exercise that most
people can do.
 Eat heart-healthy foods. This includes lots of vegetables, fruits, nuts, beans, and whole grains. It limits
foods that are high in saturated fat, such as meats, cheeses, and fried foods.
 Most women who have PCOS can benefit from losing weight. Even losing 10 lb (4.5 kg) may help get
your hormones in balance and regulate your menstrual cycle.
 If you smoke, consider quitting. Women who smoke have higher androgen levels that may contribute
to PCOS symptoms.1

Your doctor also may prescribe birth control pills to reduce symptoms, metformin to help you have regular
menstrual cycles, or fertility medicines if you are having trouble getting pregnant.

It is important to see your doctor for follow-up to make sure that treatment is working and to adjust it if needed.
You may also need regular tests to check for diabetes, high blood pressure, and other possible problems.

It may take a while for treatments to help with symptoms such as facial hair or acne. You can use over-the-
counter or prescription medicines for acne.

It can be hard to deal with having PCOS. If you are feeling sad or depressed, it may help to talk to a counselor
or to other women who have PCOS.

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