Daniel E. Stein, MD

What is polycystic ovarian syndrome (PCOS)?


 Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal diseases affecting reproductive-aged women.   In actuality, PCOS includes a spectrum of disorders rather than a  single, discrete disease.  Women may experience a variety of signs and  symptoms, and, as a result, some women may be inappropriately diagnosed  with PCOS.  Perhaps, more importantly, in many women the diagnosis is  completely missed or even ignored.
 
 One problematic aspect of PCOS is that there is no universally accepted  definition for this disease.  Most reproductive endocrinologists,  however, require the presence of hyperandrogenism (excessive "male"  hormones) and chronic anovulation (infrequent or absent ovulation  resulting in irregular menstrual cycles) to make the diagnosis.  Others  require the appearance of multiple small ovarian cysts on a vaginal  ultrasound examination.  Because other disorders of the ovary, pituitary  gland and adrenal gland can mimic the symptoms and appearance of PCOS,  these disorders should be excluded before an accurate diagnosis of PCOS  can be made.
 
 


 The symptoms of PCOS may include irregular menstrual cycles (long  intervals between periods), obesity (found in only half of patients), acne,  excessive coarse hair growth, and infertility.  Much of the hair growth  many women, and sometimes their physicians, consider "abnormal" is not  truly the result of excessive male hormones.  Hairy arms and legs are  not usually the result of abnormal hormone patterns, but rather reflect  the woman’s family or ethnic background.  "Midline" hair growth (e.g.  upper lip, chin, abdomen, between the breasts and/or buttocks) is more  suspicious for PCOS. 
 
 Some women with PCOS also have metabolic disturbances characterized by  resistance to the hormone insulin.  This hormone, produced in the  pancreas, stimulates the cells of the body to absorb and utilize  glucose, a sugar used by the body as a source of energy.  In women with  PCOS, the cells of the body are often resistant to insulin action and  glucose is not utilized efficiently.  It is therefore stored for later  use in the form of fat, hence the increased obesity and abnormal glucose levels  in some women with PCOS.  Interestingly, even some thin women with PCOS  exhibit insulin resistance.  It is important for women with PCOS to  realize that excessive fat tissue, insulin resistance and other hormonal  aberrations put them at higher risk for coronary artery disease and  diabetes.  Furthermore, loss of ovulation and infrequent periods  increase their risk for cancer of the uterus.  Therefore, PCOS is a  potentially serious disease and must not be ignored by women or their  physicians.
 
 


 While many physicians empirically diagnose a woman with PCOS based on  the clinical features mentioned above, proper diagnosis requires  obtaining blood samples for a variety of hormones, including those  produced by the ovaries, adrenal glands, pituitary gland and thyroid  gland.  A full physical examination and vaginal ultrasound are also  important.  Cholesterol, triglyceride, glucose and insulin screening should also be part of a complete evaluation.
 
 


 The truth is, no one really knows what causes this disease.  There is  certainly a miscommunication between the hypothalamus (within the  brain), pituitary gland (at the base of the brain), ovary and fatty  tissue.  Where the miscommunication originates from is a matter of great  controversy and remains unknown.  There is definitely a higher  incidence of PCOS within certain families but the genetic basis for the  disease has not yet been fully elucidated.
 
 


 The treatment of PCOS depends primarily on the symptoms exhibited by the  patient and whether or not the patient desires to become pregnant.

Anovulation and irregular menstrual cycles:


     For women who are not presently interested in childbearing, oral  contraceptive (birth control) pills are very effective at providing  regular cycles, reducing undesired "male" hormone levels and minimizing  the risks of uterine cancer.  Progesterone, a hormone produced by the  ovaries of ovulatory women, can be used to induce regular cycles.
     
     Those women who desire fertility can be placed on Clomiphene Citrate  therapy for 3-4 months.  Use of this medication for more than 3 or 4  months is unlikely to result in pregnancy and may waste valuable time.   Furthermore, women over age 35 may have a lower response to Clomiphene  Citrate and should consider the use of injectable fertility medications  in order to more effectively induce ovulation.


     Besides oral contraceptive pills, other medications are commercially  available for the treatment of hirsutism.  The most common of these are  Spironolactone and Finasteride.  They are effective at preventing new  hair growth but do not rid the body of existing hair.  Therefore, they  should be used in conjunction with mechanical hair removal methods such  as electrolysis.  Also, the effects of these medications on developing  fetuses are not well-established and therefore, women should use  contraceptive measures while taking these medications.


     As in other obese women, treatment is based on the restriction of  calorie intake and an increase in the performance of aerobic exercise.   Women should consult with a nutritionist to create a diet that is low in  fat and carbohydrates and provides adequate protein.  Low-impact  exercise programs (for 30 minutes per day 4-5 times per week) are  optimal.  Weight-lifting may also be helpful as increased muscle mass  increases calorie consumption.

Insulin resistance and glucose abnormalities: 


     Weight reduction will greatly improve not only insulin resistance,  but also help regulate menstrual cycles, improve fertility and reduce  male hormone levels.  In addition, weight loss will lower the risks of  coronary artery disease and uterine cancer.  Recently, two medications,  Metformin and Troglitazone, have been shown to effectively improve  insulin sensitivity in women with PCOS and help regulate menstrual  cycles.  They can be considered as an adjunct to weight loss and  exercise in some patients.


 PCOS is a common, varied and complex disease.  However, in most  patients, it can be managed effectively to help patients improve their  fertility and lead healthier lifestyles.

Dr. Daniel Stein is a reproductive endocrinologist at Brooklyn IVF. This article was written in connection with the American Infertility Association’s Symposium on PCOS held on October 17, 1999.

Articles

Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal diseases affecting reproductive-aged women. In actuality, PCOS includes a spectrum of disorders rather than a single, discrete disease.

Daniel E. Stein, MD

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Polycystic Ovary Syndrome