Polycystic Ovary Syndrome
I see a significant number of young women with PolyCystic Ovary Syndrome (PCOS), both privately and on the NHS. The aim of the medical consultation is for the patient to understand the condition better and receive the right advice. The diagnosis is confirmed with the help of a thorough history from the woman and appropriate scans and tests. Management and treatment is based on individual patient needs and combines lifestyle changes and advice, with or without medication.
This is a heterogeneous endocrine condition where small cysts (not painful or cancerous) may be seen on one or both ovaries and may be responsible for a variety of symptoms. It is important to remember that not all women will have all symptoms and signs of PCOS, even if they have the condition.
Medical Definition of PCOS requires 2 of 3 of the following criteria:
- Oligo –and/or anovulation (not producing eggs on a regular basis)
- Hyperandrogenism (clinical symptoms as a result of increased male hormone, testosterone and/ or abnormal biochemical (lab tests)
- Polycystic ovaries (>12 or more follicles measuring 2 –9mm in diameter and /or increased ovarian volume (>10cm3)
(2003 ASRM/ESHRE Rotterdam PCOS consensus workshop)
PCOS is an extremely common problem, with approximately 20% (2 in 10) of women in the reproductive age group showing signs of polycystic ovaries on a pelvis ultrasound scan. 10% (1 in 10) of women will have clinical symptoms or biochemical evidence of PCOS
This is still a poorly understood condition. The most likely explanation is that the ovary makes an excess of testosterone, either spontaneously with no external drive (ovarian dysfunction) or as a result of the action of insulin (reduced insulin sensitivity in peripheral tissues, leading to increased levels of insulin. It is thought that obesity itself may be a trigger) There may be a genetic predisposition (Polygenic) (Type 2 DM, premature hair loss in male relatives). The condition can also run in families.
Symptoms of PCOS can range from weight gain to fertility problems. The most common symptoms are unwanted hair growth, acne, irregular periods, and a failure to ovulate. Half of the women will be overweight with truncal obesity (weight around the middle), the syndrome is also seen in women of normal body weight. Infrequent periods or no periods (Oligomenorrhoea/amenorrhoea), Inability to conceive (Anovular infertility), Excess facial/body hair (Hirsutism), Bad skin (Acne), Scalp hair loss (Alopecia/Male pattern baldness) and Weight Gain can also be a feature.
Investigations to diagnose PCOS include a pelvic ultrasound (characteristic `string of pearls` cystic appearance) and blood hormone levels which typically show elevated testosterone and luteinising hormone levels. However, a third of women with PCOS may have normal ultrasound or hormone levels. Other tests include fasting glucose lipids and triglyceride levels. Blood tests may have to be done after fasting for 12 hours and also timed with your menstrual cycle. For women who are not sexually active, the pelvic scan is not an internal scan and is done by scanning the abdomen (tummy). It is not a painful procedure. These tests help to confirm the diagnosis of PCOS and rule out other rarer conditions that may cause similar symptoms.
There appears to be an increased risk in overweight women with PCOS of the conditions listed below. The key underlying abnormality that leads to long term problems appears to be insulin resistance – hyperinsulinaemia in the presence of normoglycemia (normal blood sugars). It is as yet undetermined in non obese women with the condition. Gestational diabetes (Diabetes in pregnancy)- (A glucose tolerance test GTT- may be recommended, Adult onset (non insulin dependent) Type II diabetes /Insulin Resistance, Cardiovascular disease (heart disease), Possible Atherosclerosis/Hypertension (high blood pressure) and Endometrial hyperplasia/cancer (womb cancer in women with prolonged amenorrhoea (no periods).
Lifestyle changes (sensible healthy diet, low in saturated/Trans fats and regular exercise) is the key to managing PCOS and its symptoms. Losing weight under guidance will often result in many of the symptoms getting better, especially menstrual problems. (PCOS Nutrition and health leaflet) There are several medications that can be used to manage PCOS, but this will need to be individualised to each patient. Once a diagnosis of PCOS is made, women should be counselled of the possible long term risks. They should be advised of the importance of a sensible diet and regular exercise. Siblings should also be offered advice concerning detection and management of PCO syndrome. Management options for PCOS, apart from diet and exercise include the use of oral contraceptive pill, insulin sensitising agents (Metformin), fertility treatment and laparoscopic ovarian drilling. Treatment has to be individualised and monitored carefully.
Fertility problems in PCOS usually arise from not releasing eggs from the ovaries (anovulation). Not all women have this problem of anovulation. Losing weight and following a healthy lifestyle, if overweight, will significantly improve fertility chances. There are also simple treatments available for most cases and only a small number of women will need to see a fertility specialist.
Long term follow up is ideally recommended. However, there are no strict guidelines as to how often and who should be doing this. This can be discussed in more detail at the consultation and individual recommendations made.
You may find this group helpful Verity – Polycystic ovaries self help group (www.verity-pcos.org.uk)
Nitu Bajekal Consultant Gynaecologist Updated Jan 2009