Polycystic Ovary Syndrome

 

Polycystic ovary syndrome is a common hormonal disorder that affects 5%-10% of women. The diagnosis of PCOS is made when a woman has at least two of the following three characteristics:

  • Inability to release an egg from the ovaries on a regular monthly basis.
  • Increased male hormone levels and/or an increase in hair in the midline of the body known as hyperandrogenism.
  • Polycystic-appearing ovaries on ultrasound. In patients with PCOS, multiple small follicles develop in the ovaries that appear as cysts, hence the term “polycystic.” These small cysts are actually immature ovarian follicles that failed to mature and ovulate.
Ultrasound Pic

Ultrasound picture of a polycystic ovary

Because of the variable nature of PCOS, its diagnosis is based upon the combination of clinical, ultrasound, and laboratory features.

PCOS Fertility Specialist in Long Island, NY

Polycystic ovary syndrome is a condition associated with hormonal imbalances that cause the ovaries to overproduce androgens. Symptoms of PCOS include hirsutism; acne; irregular, absent, or heavy menstrual periods; lack of ovulation; and infertility. More than 50% of PCOS patients also are overweight or obese, but that is not part of the definition, and some women are of normal weight. Despite persistent questions surrounding the cause of PCOS, many advances have been made in treating this disorder.

Other diseases must be excluded before the diagnosis of PCOS can be made:

  • Unexplained hirsutism
  • Menopause
  • Ovarian or adrenal tumor (excessive production of androgens)
  • Non-classical adrenal hyperplasia (excessive production of androgens by the adrenal gland)
  • Cushing syndrome (excessive production of cortisol by the adrenal gland)
  • Medications (anabolic steroids, danazol, phenytoin, minoxidil, and diazoxide.natural supplements such as DHEA and androstenedione)
Ovaries Pic

Irregular Menstrual Periods

The ovulatory cycle is easily affected by hormonal abnormalities. Overproduction or underproduction of certain hormones can have devastating results. Excess LH or insulin may cause the ovaries to overproduce androgens. Insufficient FSH may impair ovarian follicle development and prevent ovulation, resulting in infertility. Eventually, the multiple small cysts formed in the ovary from follicles that failed to mature and ovulate result in the PCOS appearance on ultrasound. Not all women with PCOS have ovaries with this appearance. Lack of ovulation in PCOS results in continuous high levels of estrogen and insufficient progesterone. Unopposed by progesterone, ongoing estrogen exposure may cause the endometrium to become excessively thickened, which can lead to heavy and/or irregular bleeding. Over many years, endometrial cancer may result due to continuous stimulation by high levels of estrogen unopposed by progesterone.

 

Hirsutism (male pattern hair growth)

Androgen sensitive location for hair growth:

More common                      

Upper lip

Beard area

Breasts

Lower abdomen

Inner thighs

Lower back

 

Less common

Chest and sternum

Upper abdomen

Upper back

Diagnosing Hirsutism

During your initial medical consultation, your physician will try first to make a distinction between terminal hairs growing in a masculine pattern indicating hirsutism and hair growth due to genetic or ethnic predisposition rather than a hormone disorder. If you are diagnosed with hirsutism, your physician may perform blood tests, ultrasound, special x-rays, and hormone tests to evaluate the function of your ovaries and adrenal glands. After identifying the causes of hirsutism, your physician can recommend appropriate treatment. Any unwanted hair remaining after treatment may be removed by a variety of cosmetic treatments, including laser and electrolysis.

Early Diagnosis

If you have had menstrual irregularity and/or progressive hirsutism since puberty, you should be evaluated for PCOS. If you are diagnosed with PCOS and you have female children, you should watch them for symptoms and inform them that they are at risk, since there is a genetic tendency to inherit the syndrome. Early treatment of PCOS may decrease the development of acne and hirsutism.

 

Long-term Considerations

Women with PCOS are at risk for metabolic syndrome. Metabolic syndrome is when women develop multiple risk factors for heart disease. Metabolic syndrome is common in women with PCOS, even adolescents. Women may have prediabetes, particularly those with insulin resistance, and may be at an increased risk for diabetes, heart disease, cholesterol abnormalities, and endometrial cancer.

graph

PCOS TREATMENT

 

If you are diagnosed with PCOS, treatment will depend upon your goals. Some patients may be concerned primarily with fertility, while others are more concerned about menstrual cycle regulation, hirsutism, or acne. Regardless of your primary goal, PCOS should be treated because of the long-term health risks such as heart disease and endometrial cancer.

 

Weight Loss

Obesity commonly is associated with PCOS. Fatty tissues produce excess estrogen, which in turn contributes to insufficient FSH secretion by the pituitary gland. Insufficient FSH prevents ovulation and may worsen PCOS. In addition, obesity is associated with the development or worsening of insulin resistance, which may further increase androgen production by the ovaries.

Diet and Exercise

Increasing physical activity is an important step in any weight reduction program. Start slowly with an aerobic activity such as walking or swimming. Increase speed and distance gradually. Regular activity improves state of mind as well as aiding in weight reduction. Recommendations include:

  • 3 to 4 exercise periods each week with at least 30 minutes of aerobic exercise
  • Get a fit bit and walk 10,000 steps a day
  • Eat a healthy and balanced diet
  • Don’t skip breakfast!

Extreme cases of obesity, unresponsive to medical management and behavioral modification, may be treated with bariatric surgery. Surgical risks have decreased over time and many procedures are performed in a minimally invasive way.

Hormonal Treatment

Hormonal treatment frequently is successful in temporarily correcting the problems associated with PCOS. If treatment is stopped, however, symptoms usually reappear. If you are not trying to conceive, birth control pills may be your best hormonal treatment. Birth control pills decrease ovarian hormone production and help reverse the effects of excessive androgen levels. However, birth control pills are not recommended if you smoke and are over age 35. If you also have hirsutism, your physician may prescribe spironolactone, alone or combined with birth control pills. Rarely, GnRH analogs may be used to decrease ovarian androgen production. If you are not concerned with fertility or contraception, and hirsutism is not a problem, you can take progesterone at regular intervals to regulate your menstrual bleeding and prevent the endometrial problems associated with excessive estrogen exposure.

PCOS & Trying For A Baby‎ in New York

Infertility

If fertility is your immediate goal, ovulation may be induced with clomiphene citrate. Clomiphene is simple to use, is relatively inexpensive, and works well to induce ovulation in many patients. Clomiphene causes the pituitary gland to increase FSH secretion. Sometimes increasing the dosage or the length of treatment is necessary. Approximately 10% of pregnancies with clomiphene are twins; triplets are more are rare. Your physician also may recommend a steroid drug designed to suppress the adrenal gland to supplement clomiphene therapy. If consistent ovulation is not noted with clomiphene, the use of another oral medication, Letrozole, may be considered. Whether Letrozole results in the same pregnancy rates as clomiphene citrate remains to be determined. Letrozole is not approved by the FDA for the induction of ovulation. Letrozole should not be given to pregnant women because it might lead to abnormalities of the reproductive system in any resulting children.

If clomiphene or letrozole do not induce ovulation, or you do not get pregnant within six ovulatory cycles, your physician may prescribe gonadotropins. There are many types of gonadotropins used alone or in combination for ovulation induction. They include human menopausal gonadotropin (hMG), purified human follicle-stimulating hormone (hFSH), recombinant follicle-stimulating hormone (rFSH), and human chorionic gonadotropin (hCG). Gonadotropins are more expensive and have a higher incidence of side effects such as hyperstimulation (excessive swelling) of the ovaries and a higher rate of multiple pregnancy such as twins or triplets.

Your needs and response to therapy will determine the appropriate medication for ovulation induction. For additional information, consult the ASRM patient information booklet titled “Medications for Inducing Ovulation” and the patient fact sheet titled Insulin-sensitizing Agents.

In very rare cases, ovulation is not achieved with either clomiphene or gonadotropins, and ovarian surgery may be tried to stimulate ovulation. Surgical procedures such as ovarian drilling may be performed through laparoscopy. Although these procedures have helped some patients to ovulate, they also may have adverse effects on future fertility by causing adhesions (scar tissue) and are generally treatments of last resort.

 

Medical Therapy for Hirsutism

There are a variety of specific medical and surgical treatments that your physician may recommend based on your diagnosis and severity of hirsutism (Table 3). Most medications used to treat hirsutism are approved by the US Food and Drug Administration (FDA) but not for this specific indication. Nevertheless, research has documented their effectiveness.

 

Treatment of Hirsutism

 

Medications                                                       

Birth control pills

Androgen receptor blockers

Spironolactone

Flutamide

Glucocorticosteroids

Dexamethasone

Prednisone

Methylprednisolone

Enzyme inhibitors

Finasteride

GnRH analogs

 

Cosmetic

Shaving

Eflornithine cream

Waxing

Bleaching

Plucking

Depilatory agents

Electrolysis

Laser

MEDICATIONS

Birth Control Pills (Oral Contraceptives)

Birth control pills are the most commonly suggested hormonal treatment for hirsutism. They prevent ovulation and decrease the production of androgens by the ovaries. Estrogen in the pills causes the liver to produce and release more of a protein (sex hormone-binding globulin) that binds to androgens and reduces their action. In addition to slowing excessive hair growth, the pills provide the added advantages of regulating the menstrual cycle and protecting against unwanted pregnancies.

 

Metformin

This medication is an insulin-sensitizing agent that helps to reduce circulating insulin and androgen levels and restores normal ovulation in some women with PCOS.  It can also assist the fertility medications to help with ovulation.  Side effects can include gastrointestinal irritation, especially diarrhea, flatulence, and abdominal bloating.  This can be improved with low carbohydrate diets.  Metformin should be avoided in women with kidney, lung, liver, or heart disease.  It should also be stopped when having radiology exams that use iodine (such as hysterosalpingograms or CT scans).  Lactic acidosis is a rare but serious adverse effect of Metformin.

Antiandrogenic Medications

Spironolactone, a diuretic or “water pill,” often is prescribed in combination with birth control pills. It has been found to directly block the effects of androgens in hair follicles and has been used to treat hirsutism. Side effects may include dry skin, heartburn, headaches, irregular vaginal bleeding, and fatigue. More than two-thirds of the women on high-dose spironolactone will have a significant decrease in hirsutism.

 

Steroid Medications

Low doses of steroids may be prescribed for overactive adrenal glands. Some women taking them experience dizziness during the day, experience mood changes, or have difficulty falling asleep, although these complaints generally improve after the first few days. These drugs may have serious side effects, including weight gain, thinning of the skin and bones, and decreased defense against infection. However, these side effects are seldom seen at the low doses used for treating hirsutism.

 

GnRH Analogs

Severe forms of hyperandrogenism may be treated by a gonadotropin-releasing hormone (GnRH) analog. These medications treat hirsutism by suppressing ovarian androgens to very low levels. They also suppress estrogen and may cause menopausal-like symptoms. GnRH antagonists also are effective and may be approved for use for this purpose in the future. Use of these medications requires close supervision by your physician. An estrogen and/or a progestin often are administered with the GnRH analog to prevent bone loss.

 

Cosmetic Therapy

Cosmetic removal of hair in women with hormonally associated hirsutism always should be accompanied by medical therapy in order to be successful.

 

PSYCHOLOGICAL ASPECTS OF HIRSUTISM AND PCOS

Dealing with hirsutism and PCOS can be emotionally difficult. You may feel unfeminine, uncomfortable, or self-conscious about your excessive hair growth or weight, as well as worried about your ability to have children. Even though you may be embarrassed to share these feelings with other people, it is very important that you talk to your physician as soon as possible to explore the medical and cosmetic treatments available to treat these disorders. It also is important for you to realize that these are very common problems experienced by many women.

SUMMARY

PCOS can cause hirsutism, acne, irregular or heavy menstrual periods, lack of ovulation, and infertility. It also is associated with an increased risk of diabetes, uterine cancer, high cholesterol, and heart disease. Despite questions surrounding the causes of PCOS, advances have been made in both understanding and treating the condition. If you are diagnosed with hirsutism or PCOS, it is best to seek a specialist in PCOS who can addressed your goals and concerns and discuss the best treatment option for you.