Polycystic Ovarian Syndrome (PCOS)

• Polycystic ovarian syndrome (PCOS), also known by the name Stein-Leventhal syndrome, is a hormonal problem that causes women to have a variety of symptoms.
• It should be noted that most women with the condition have a number of small cysts in the ovaries. However, women may have cysts in the ovaries for a number of reasons, and it is the characteristic constellation of symptoms, rather than the presence of the cysts themselves, that is important in establishing the PCOS diagnosis.
• PCOS occurs in 5% to 10% of women and is the most common cause of infertility in women.
• PCOS symptoms may begin in adolescence with menstrual irregularities , or a woman may not know she has PCOS until later in life when symptoms and/or infertility occur. Women of all ethnicities may be affected.

Symptoms of polycystic ovarian syndrome (PCOS) include delay of normal menstruation (primary amenorrhea), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea).

The principal signs and symptoms of PCOS are related to menstrual disturbances and elevated levels of male hormones (androgens).

Menstrual disturbances can include delay of normal menstruation (primary amenorrhea), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea ). Menstrual cycles may not be associated with ovulation (anovulatory cycles) and may result in heavy bleeding.

Symptoms related to elevated androgen levels include acne, excess hair growth on the body (hirsutism), and male-pattern hair loss.

Other PCOS signs and symptoms include:

• obesity and weight gain,
• elevated insulin levels and insulin resistance,
• oily skin,
• dandruff,
• infertility,
• skin discolorations,
• high cholesterol levels,
• elevated blood pressure, and
• multiple small cysts in the ovaries.

Any of the above symptoms and signs may be absent in PCOS, with the exception of irregular or no menstrual periods. All women with PCOS will have irregular or no menstrual periods.

Women who have PCOS do not ovulate regularly; that is, they do not release an egg every month. This is why they do not have regular periods and typically have difficulty conceiving.

The cause of PCOS is unknown, and it is likely to be the result of a number of both genetic (inherited) as well as environmental factors. Women with PCOS often have a mother or sister with the condition, and researchers are examining the role that genetics or gene mutations might play in its development.

• The ovaries of women with PCOS frequently contain a number of small cysts, hence the name poly, which means many cystic ovarian syndrome. A similar number of cysts may occur in women without PCOS. Therefore, the cysts themselves do not seem to be the cause of the problem.
• A malfunction of the body's blood sugar control system (insulin system) is frequent in women with PCOS, who often have insulin resistance and elevated blood insulin levels. Researchers believe that these abnormalities may be related to the development of PCOS.
• It is also known that the ovaries of women with PCOS produce excess amounts of male hormones known as androgens. This excessive production of male hormones may be a result of or related to the abnormalities in insulin production.
• Another hormonal abnormality in women with PCOS is the excessive production of luteinizing hormone (LH), which is produced by the pituitary gland, which is involved in stimulating the ovaries to produce hormones.
• Other possible contributing factors in the development of PCOS may include a low level of chronic inflammation in the body and fetal exposure to male hormones.

The PCOS diagnosis is generally made through clinical signs and symptoms. The doctor will want to exclude other illnesses that have similar features, such as low thyroid hormone blood levels (hypothyroidism) or elevated levels of a milk-producing hormone (prolactin). Also, tumors of the ovary or adrenal glands can produce elevated male hormone (androgen) blood levels that cause acne or excess hair growth, thus mimicking the symptoms of PCOS.

• Other laboratory tests can be helpful in making the diagnosis of PCOS. Serum levels of male hormones ( DHEA and testosterone ) may be elevated. However, levels of testosterone that are highly elevated are common with PCOS and call for additional evaluation.
• Additionally, levels of luteinizing hormone involved in ovarian hormone production are elevated.
• The cysts (fluid filled sacs) in the ovaries can be identified with imaging technology. (However, as noted above, women without PCOS can have many cysts as well.) Ultrasound, which passes sound waves through the body to create a picture of the kidneys, is used most often to look for cysts in the ovaries. Ultrasound imaging employs no injected dyes or radiation and is safe for all patients including pregnant women. It can also detect cysts in the kidneys of a fetus.
• Because women without PCOS can have ovarian cysts, and because ovarian cysts are not part of the definition of PCOS, ultrasound is not routinely ordered to diagnose PCOS. The diagnosis is usually a clinical one based on the patient's history, physical examination, and laboratory testing.
• More powerful and expensive imaging methods such as computed tomography (CT scan) and magnetic resonance imaging (MRI) can also detect cysts, but they are generally reserved for situations in which other conditions that may cause related symptoms, such as ovarian or adrenal gland tumors are suspected. CT scans require X-rays and sometimes injected dyes, which can be associated with some degree of complications in certain patients.

• Treatment of PCOS depends partially on the woman's stage of life.
• For younger women who desire birth control, the birth control pill, especially those with low androgenic (male hormone-like) side effects can cause regular periods and prevent the risk of uterine cancer.
• Another option is intermittent therapy with the hormone progesterone. Progesterone therapy will induce menstrual periods and reduce the risk of uterine cancer, but will not provide contraceptive protection.
• For acne or excess hair growth, a water pill (diuretic) called spironolactone (Aldactone) may be prescribed to help reverse these problems.
• The use of spironolactone requires occasional monitoring of blood tests because of its potential effect on the blood potassium levels and kidney function.
• Eflornithine (Vaniqa) is a prescription cream that can be used to slow facial hair growth in women.
• Electrolysis and over-the-counter depilatory creams are other options for controlling excess hair growth.

Women with PCOS are at a higher risk for a number of illnesses, including high blood pressure, diabetes, heart disease , and cancer of the uterus(endometrial cancer).

• Because of the menstrual and hormonal irregularities, infertility is common in women with PCOS. Because of the lack of ovulation, progesterone secretion in women with PCOS is diminished, leading to long-term unopposed estrogen stimulation of the uterine lining. This situation can lead to abnormal periods, breakthrough bleeding, or prolonged uterine bleeding.
• Unopposed estrogen stimulation of the uterus is also a risk factor for the development of endometrial hyperplasia and cancer of the endometrium (uterine lining). However, medications can be given to induce regular periods and reduce the estrogenic stimulation of the endometrium (see below).
• Obesity is associated with PCOS. Obesity not only compounds the problem of insulin resistance and type 2 diabetes (see below), but also imparts cardiovascular risks. PCOS and obesity are associated with a higher risk of developing metabolic syndrome , a group of symptoms, including high blood pressure, that increase the chances of developing cardiovascular disease. It has also been shown that levels of C-reactive protein (CRP), a biochemical marker that can predict the risk of developing cardiovascular disease, are elevated in women with PCOS. Reducing the medical risks from PCOS-associated obesity is important.
• The risk of developing prediabetes and type 2 diabetes is increased in women with PCOS, particularly if they have a family history of diabetes. Obesity and insulin resistance, both associated with PCOS, are significant risk factor for the development of type 2 diabetes. Several studies have shown that women with PCOS have abnormal levels of LDL ("bad") cholesterol and lowered levels of HDL ("good") cholesterol in the blood. Elevated levels of blood triglycerides have also been described in women with PCOS.
• Changes in skin pigmentation can also occur with PCOS. Acanthosis nigricans refers to the presence of velvety, brown to black pigmentation often seen on the neck, under the arms, or in the groin. This condition is associated with obesity and insulin resistance and occurs in some women with PCOS.

Women with PCOS who want to become pregnant have a few options to consider, which include medications, lifestyle modifications, and surgical procedures. 

• A medication called clomiphene can be used to induce ovulation (cause egg production).
• Weight loss can normalize menstrual cycles and often increases the possibility of pregnancy in women with PCOS.
• Other, more aggressive, treatments for infertility (including injection of gonadotropin hormones and assisted reproductive technologies like in vitro fertilization or IVF) may also be required in women who desire pregnancy and do not become pregnant on Clomid therapy.
• Metformin is a medication used to treat type 2 diabetes. This drug affects the action of insulin and is useful in reducing a number of the symptoms and complications of PCOS. Metformin has been shown to be useful in the management of irregular periods, ovulation induction, weight loss, as well as the prevention of type 2 diabetes and gestational diabetes mellitus in women with PCOS.
• Obesity that occurs with PCOS needs to be treated because it can cause numerous additional medical problems. The management of obesity in PCOS is similar to the management of obesity in general. Weight loss can help reduce or prevent many of the complications associated with PCOS, including type 2 diabetes and heart disease. Consultation with a dietician on a frequent basis is helpful until just the right individualized program is established for each woman.
• A surgical procedure known as ovarian drilling can help induce ovulation in some women who have not responded to other treatments for PCOS. In this procedure a small portion of ovarian tissue is destroyed by an electric current delivered through a needle inserted into the ovary. This is an older procedure which is only rarely utilized.