Polycystic Ovary Syndrome

What is this?

A common cause of irregular menstrual periods is the syndrome called Polycystic Ovary Syndrome (PCOS). The classical description described a patient with irregular or absent menstrual periods (or periods where the woman does not ovulate called anovulatory) excess sexual hairs (hirsutism) and obesity associated with enlarged ovaries with multiple small (2-8mm) cysts seen on ultrasound scanning. However recently it has been recognised that PCOS is a dynamic disorder where the symptoms and manifestations change and vary in the same woman throughout her life. Even the definition has been extended to include patients with menstrual irregularity and signs of androgenicity (e.g. hirsutism, scalp hair loss, acne) even though the ovaries show no obvious small cysts on ultrasound.

Published studies indicate that the condition is very common possibly affecting one fifth to one third of premenopausal women.

The cause is unclear. The condition would appear to be inherited but environmental influences are implicated such as the development of obesity. Obesity appears to increase the body’s resistance to the hormone insulin exacerbating or even causing the condition for insulin influences hormone production in the ovary.The small cysts are normal ‘eggs’ called follicles arrested at a certain stage of their development. Normally these arrested follicles would be removed by the ovary but for some reason these are not removed in PCOS. There is however NO evidence to suggest any cancer risk in these ovaries.

There is a wide spectrum of clinical symptoms and signs as follows;

1. Obesity affects 40%
2. Menstrual disorders affect 66%
        Irregular periods in 50%
        Lack of periods (amenorrhoea) in 20%
        Heavy periods in 4%
NB Regular periods still occur in 30%
3. Excess androgenicity in 48%
        i.e. hirsutism (i.e. excess hairs on body , face, upper thighs)
        i.e. acne
        i.e. alopecia which is scalp hair loss
4. Infertility in 75%

NB that 20% of women with PCOS have no symptoms and may be unaware they have the condition

Yes as follows;
1. Raised insulin with partial resistance to the insulin
2. Raised blood androgen hormones for the female. Normally a female does produce small amounts of androgen or male          hormones such as testosterone but in PCOS the level of testosterone and another called androstenedione are slightly           elevated.
3. Raised LH produced by the pituitary
4. In some patients a raised prolactin level produced by the pituitary

The possible late problems appear to be;
1. Raised blood levels of lipids which are fats which can cause premature cardiovascular disease such as heart attacks and           strokes
2. Diabetes mellitus
3. Cardiovascular disease and hypertension

As the cause is as yet unclear the treatment is directed towards the symptoms.

Long term reduced caloric diet will be required with increased physical exercise. Even a modest reduction in weight by 5% produces significant improvement in the blood androgen and insulin levels with improvement in fertility.

1. Dianette may be effective if taken for at least one year and is licensed for hirsutism in UK. However hirsutism tends to reappear if the medicine is then ceased although recent reports suggest that 4 years therapy is associated with a less risk of return of hairs.
2. Cyproterone acetate is of proven effectiveness in many women but must be taken with a contraceptive pill (usually dianette or just oestrogen) to prevent pregnancy for otherwise the unborn child might be damaged.There are risks with this therapy as outlined in the drug section on cyproterone.
3. Flutamide has been used with the contraceptive pill (to prevent pregnancy) but is not licensed for hirsutism and has the potential danger of lethal liver failure. For this reason it is usually not recommended.
4. Insulin sensitisers. The newest in this range is the oldest called metformin. Metformin has been used in diabetes mellitius for decades as it increases the sensitivity to insulin. By using metformin in PCOS, the woman’s insulin is made more sensitive i.e. works better, and menstrual periods return and possibly hirsutism lessens. Combination of metformin with dianette is advocated by some but has yet to be proven conclusively to be any better than dianette alone.
Troglitazone also is an insulin sensitiser but has had to be withdrawn from the UK market due to liver damage. Newer agents of the type without liver damage potential will be soon available and may be effective.
5. Electrolysis produces permanent physical treatment for unwanted hairs but can be time consuming and expensive. Regrowth regrettably can and does sometimes occur.
6. Laser therapies are available. There are many differing types of laser therapy in the market with differing effectiveness and safety as regards scarring. Nevertheless repeated treatment is necessary for a satisfactory effect as only hairs in their growing phase are removed by these techniques.

Infertility

1. Clomiphene is often used to induce fertility. Usually the patient will be seen by an endocrine gynaecologist and treatment assessed with ovarian ultrasound monitoring.
2. Metformin has also been shown to induce fertility especially in overweight women with insulin resistance
3. Gonadotrophins (FSH) are used to induce fertility where clomiphene has failed. These require specialist care so as not to overstimulate the ovaries and produce multiple fetuses in one pregnancy.
4. Laparoscopic diathermy or laser injury to the ovary can be effective in some.
5. In vitro fertisation (IVF) is also a possibility where all else has failed or is not feasible.

Here regular monitoring for the usual cardiovascular risk factors (lipids, blood pressure, weight, smoking) and diabetes would be advisable.

Where can I get more information?

Try self help group 'Verity', 52-54 Featherstone Street, London  EC1Y 8RT
or
www.verity-pcos.org.uk

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Ó NHS Tayside; 2006; version 1.0

Disclaimer; no liability whatsoever is accepted for information given and all such information, especially with regard to drug usage (UK version provided), must be checked with a person’s health provider.