POLYCYSTIC OVARIAN DISEASE

The Basics

Polycystic ovarian syndrome (PCOS) is an extremely common endocrine disorder. The prevalence of PCOS is conservatively estimated to occur in 5-10% of reproductive-aged women. This disease has been recognized since at least the 1930’s. While a clinical diagnosis of PCOS may encompass several distinct subsets of patients, most experts in the field agree that there are some common clinical and laboratory aspects of this common disorder.

Most women with PCOS have ovulatory dysfunction or absent ovulation. If the egg is not released from the ovary each month in a normal fashion, this can obviously lead to infertility. Anovulation may also manifest itself by infrequent or irregular menstrual cycles. In the absence of ovulation, the ovary does not make the hormone progesterone in the second half of the menstrual cycle. Without progesterone, the lining of the uterus is not shed in an efficient and timely manner. After a number of years, this can place women with PCOS at risk for an abnormal buildup of the lining of the uterus (endometrial hyperplasia) . For this reason, women with PCOS who are not trying to get pregnant should be treated with progesterone-like medications to induce a normal menstrual period at least every 2-3 months.

Another common feature to PCOS is clinical or laboratory hyperandrogenism. This means that women with PCOS have either increased circulating amounts of or increased responsiveness to male hormones like testosterone or DHEAS. This may result in oily skin or acne and excess hair on the face, between the breasts, or on the lower abdomen. In order for the diagnosis of PCOS to be made, these abnormalities must exist in the absence of other related hormonal disorders. A qualified doctor can distinguish these disorders.

Most women with PCOS also display changes in the ovaries as viewed by ultrasound. In fact, the name itself describes the typical ultrasound findings seen in this disorder: poly (many), cystic (small collections of fluid). When the eggs in the ovaries do not develop to maturity, many small "follicles" (small fluid-filled sacs containing immature eggs) develop and can be seen on ultrasound underneath the surface of the ovaries.  A typical ultrasound is shown below:

The ovaries of women PCOS are often enlarged as well. However, most women with PCOS do not have the kind of "cysts on the ovary" that we normally think of as problematic or requiring surgery.

Another common feature of PCOS is increased body weight. Women with PCOS tend to be heavy and have trouble losing weight. One underlying mechanism behind the ovulatory irregularity and the obesity is probably insulin resistance. This means that the cells of women with PCOS do not respond as well to their bodies’ own insulin as those of someone without PCOS. This puts women with PCOS at higher risk for developing diabetes during pregnancy or later in life.

Treatment Strategies

Treatment for PCOS depends largely on an individual woman’s fertility desires. For those women not desiring immediate pregnancy, there are basically two options to help regulate menstrual cyclicity and prevent endometrial hyperplasia. The most common option is the use of oral contraceptives (birth control pills; BCPs). BCPs will give most women normal bleeding patterns and prevent hyperplasia. Since ovulation can occur unpredictably in women with PCOS, BCPs also provide adequate contraception. The hormones in BCPs will also help reduce acne and facial hair in most patients with PCOS. In women who do not require oral contraception, progesterone given for 10-12 days every 30-60 days will induce a reliable menses.

In women for whom unwanted hair growth is particularly bothersome, significant improvement can be obtained with a combination of medications. As already mentioned, BCPs are extremely useful in this regard. Other medications may include drugs that reduce the secretion of androgen hormones or interfere with their action in the skin and hair cells.

Alternatively, for women with PCOS who desire pregnancy, ovulation induction is often necessary. This involves medical treatment in order to help the ovaries release an egg each month in a reliable fashion. For many women this involves simple and relatively inexpensive oral medication. Others may require more intensive and expensive therapies utilizing injectable medications. For full coverage of ovulation inducing agents go to the section on ovulation drugs.

Finally, there are some new therapeutic options available for women with PCOS. As already mentioned, insulin resistance may represent the underlying problem for a lot of PCOS patients. A relatively new class of drugs that help sensitize the cells to the action of insulin, thereby reducing insulin resistance, has recently been shown to help induce ovulation in women with PCOS who failed previous simple therapies. Certain of these agents may also help women with PCOS to lose weight. Some of the more common drugs are: Metformin (Glucophage) and Actos.  Glucophage is much simpler to administer and is frequently associated with weight loss.  It is a general goal to obtain a weight loss of at least 10%.  Many studies have shown that a weight loss of 10% leads to a 30% pregnancy rate.  Although weigh loss is difficult to achieve and the idea of dieting is stressful for almost anyone, we have had much recent success with a variety of approaches.  The first is the Adkins type protein based diet.  This low carbohydrate diet helps to reduce insulin secretion and encourage weight loss.  Other options include the sugar buster diet or formal weight loss systems such as Weight Watchers.  Also please remember the first week of any dietary change is the worst.   If you can hang in there with week one, any diet will seem more natural. 

In women who cannot tolerate or don't conceive with oral medications such as Gllucophage or Clomid other options are available.  These include injectable ovulation medications such as Gonal-F or Follistim.  also in vitro fertilization is available with excellent results.
PCOS is a common readily treatable disorder. The challenge is for the doctor to meet the specific needs of the patient during her entire life span.

For more information about PCOS please visit the PCO support web site at: http://pcosupport.org. This site is informative and contains detailed information about the condition.