Polycystic ovaries have the typical appearance ofnumerous small cysts (undeveloped follicles) seen on ultrasound scan.
Polycystic Ovary Syndrome (known as PCOS) is diagnosed when at least two out of three following criteria are met:
- Multiple small cysts in the ovaries
- Clinical symptoms or blood test evidence of raised levels of androgens (male hormones, like the testosterone)
- Evidence that ovulation is not occurring and periods are irregular
In women with PCOS cysts are generally accompanied by an imbalance of sex hormones usually with increased levels of androgens. Blood tests show an increased level of testosterone and there may be acne and/or excessive hair growth (hirsutism) on the face and/or other parts of the body. Polycystic ovaries may be present without the whole syndrome.
As PCOS is associated with irregular periods, ovulation is unlikely to be taking place. As a result women with PCOS may experience trouble getting pregnant and if they do fall pregnant may have a slightly increased risk of miscarriage because of the hormone imbalance..
Women with PCOS also have tdifficulty controlling their weight; they are at increased risk of developing diabetes as their tissues are resistant to insulin. Other possible long term effects include increased risk of high blood pressure, heart disease and cancer of the uterus (womb). PCOS can have long term debilitating effects on a woman’s health.
Why does PCOS occur?
Exactly why is not fully understood yet. The body of a woman with PCOS may not respond to the hormone insulin. Insulin controls the amount of glucose in the blood and so a woman with PCOS may have more glucose and more insulin. High levels of insulin affect hormone production by the ovary, which can lead to an over-production of male hormones.
Investigations for PCOS
To confirm the diagnosis, the following investigations would need to be undertaken; a) ultrasound scan of the pelvis to look at the ovaries, b) blood tests to measure the levels of male hormones as well as prolactin, FSH, LH and AMH.
Treatment for PCOS
PCOS can significantly affect a woman physically, socially and psychologically. It is therefore important to tailor treatment to an individual’s main presenting symptoms and fertility plans. Treatment can include;
Weight loss and diet
If a patient is overweight or obese, the starting point must be to reduce the weight as this will help to lower the insulin levels and improve the overall hormone imbalance. Ideally BMI should be between 20-25 kg/m2. Making changes to weight for some women completely resolves the symptoms and restores periods. The most appropriate diet for women with PCOS is one that promotes stable levels of blood sugar and lower levels of insulin. Overweight and obese women with PCOS benefit from seeing a nutritionist and entering a focused nutrition programme.
Hormone preparations for irregular periods
The combined oral contraceptive pill is given to regulate periods. Some women can also take the pill Dianette which is a hormone preparation containing an anti-androgen. It is used for the treatment of acne. There are some risks associated with it and an individual risk assessment would need to be undertaken.
There are some drugs with anti-androgen properties but many of these should not be taken if a woman is planning pregnancy and without the advice of either an endocrinologist or a gynaecologist.
Metformin is a drug that increases the sensitivity of tissues to insulin, reduces insulin levels in the blood stream and therefore indirectly reduces the levels of male hormones. It may therefore help to restore ovulation, regulate periods and help to improve other symptoms including acne and hirsutism. It can have some gastro-intestinal side effects.
Treatments to improve fertility
The issue of lack of ovulation is treated initially with up to six cycles of ovulation induction agents, including Clomid or Letrozole tablets. This acts by helping to increase levels of follicle stimulating hormone (FSH). It is important that all cycles are monitored to ensure that the body does not over respond to treatment. Some women with PCOS are resistant to treatment with Clomid or Letrozole. If this is the case, other treatments include gonadotrophin hormone injections or assisted conception treatment..
Topical and cosmetic treatments
There are various treatments available to treat the issue of excessive facial hair growth. These include Eflornithine HCI Cream (Vaniqa), a non-hormonal approach that works to directly slow hair growth. Other cosmetic approaches include waxing, shaving, electrolysis and laser treatments.