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Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome (PCOS) is a term used to describe a group
of conditions which cause the ovaries to produce excessive male hormones
also known as androgens. It is a common endocrine (hormonal) disorder
in women of reproductive age. A "syndrome" is defined as a set of
symptoms associated with a disorder. PCOS is a syndrome because it
manifests as a collection of symptoms related to infrequent ovulation,
characterized by irregular menstrual periods and evidence of excess
androgens (male hormones), which can cause excessive facial hair growth,
acne, and/or male-pattern baldness. The ovaries may be enlarged with
many small follicles (tiny sacs filled with fluid), hence the name
polycystic. Although PCOS is primarily a problem of the ovaries, the
condition alters hormone levels and affects tissues throughout the
body. PCOS is a health problem that affects a woman's menstrual cycle,
fertility, hormones, insulin production, heart, blood vessels, and
appearance.
This syndrome was originally named Stein-Leventhal Syndrome in recognition
of the two physicians who, in 1935, first described the condition.
Other names for PCOS include Polycystic Ovarian disease, hyperandrogenic
chronic anovulation and functional ovarian hyperandrogenism.
An estimated five to 10 percent of women of childbearing age have
PCOS. As many as 30% of women have at least some characteristics of
the syndrome. It is a leading cause of infertility. In fact, PCOS
causes 75 percent of all cases of anovulatory infertility.
Normal Ovarian Function
An understanding of the normal menstrual cycle and how the ovaries
normally work is important to gain an insight into the nature or physiology
of PCOS. The ovaries serve two important functions in the reproductive
age: they produce eggs and release two hormones, estrogen and progesterone
into the blood.
A normal menstrual cycle is dependent upon regular cyclic changes
in the blood hormone levels of estrogen and progesterone. A woman's
ovaries have follicles, which are tiny sacs (cysts) filled with liquid
that hold the eggs. Each month about 20 eggs start to mature, but
usually only one becomes large and dominant. The growing follicle
produces the hormone estrogen. As the one egg grows, the follicle
accumulates fluid in it. When that egg matures, the follicle appears
as a cyst on the surface of the ovary, breaks open or ruptures and
releases the egg so that it can travel through the fallopian tube
for fertilization. When the single egg leaves the follicle, ovulation
takes place. Ovulation occurs approximately two weeks before the onset
of the menstrual period. After ovulation occurs, the empty follicle
in the ovary collapses (forms the corpus luteum) and produces progesterone
in the second half of the menstrual cycle. Progesterone helps prepare
the uterine lining for a possible pregnancy. If conception occurs,
the egg fertilizes in the tube where it remains for 3-4 days, before
entering the uterus where it embeds (implants) in the endometrium
(uterine cavity lining). If there is no implantation, the levels of
estrogen and progesterone declines, about 2 weeks after ovulation
and the uterine lining is shed. This results in menstruation and the
cycle begins again.
The development of follicles in the ovary is driven by two hormones
called gonadotropins produced in the brain. In response to Follicle
Stimulating Hormone (FSH), the follicles begin to grow. In response
to Leutinizing hormone (LH), the follicle produces androgens and ovulation
or the release of egg from the follicle occurs.
PCOS and Disruption on Normal Ovarian Function
The ovulatory cycle is easily disrupted by hormonal changes. The disruption
may occur because of insufficient FSH or excessive LH production in
the brain. In women with PCOS, the ovary doesn't make all of the hormones
it needs for any of the eggs to fully mature. The follicles may start
to grow and accumulate fluid. But no one egg becomes large enough.
Instead, some may remain as immature follicles and continue to produce
estrogen. Since no egg matures or is released, ovulation does not
occur and the hormone progesterone is not made. Also, the immature
follicles produce male hormones, which continue to prevent ovulation.
Lack of ovulation results in infertility.
It is the abnormal hormone levels that lead to irregular periods in
women with PCOS. As a result, the inside lining of the uterus - called
the endometrium - is exposed to the hormone estrogen for great lengths
of time without being exposed to the hormone progesterone. It is the
cyclic rise and fall in both estrogen and progesterone that cause
menstrual bleeding. In the case of PCOS, there can be prolonged lengths
of time without the production of progesterone. During this time the
endometrium is continuously exposed to estrogen. The result of this
prolonged estrogen exposure is the buildup /growth of the endometrium.
When the endometrium becomes too thick, heavy and irregular bleeding
can occur. Also when the endometrium is exposed to estrogen for prolonged
periods of time, cell changes can occur in which the cells of the
endometrium become abnormal and, if not treated appropriately, can
develop into cancer of the uterus. Progesterone prevents this build-up
of the endometrium.
If elevated androgen levels persist for a long time, hirsutism and
acne may occur.
The exact cause of PCOS is unknown. Women with PCOS frequently have
a mother or sister with PCOS. Some studies are looking at the possibility
of a genetic link to this disorder. Researchers are also looking at
the relationship between PCOS and the body's ability to make insulin.
Since some women with PCOS make too much insulin, it's possible that
the ovaries react by making too many male hormones, called androgens.
This can lead to acne, excessive hair growth, weight gain, and ovulation
problems.
Signs and Symptoms of PCOS
Signs and symptoms of PCOS often begin around the time of puberty,
but for others, symptoms do not develop until adulthood. Symptoms
vary among women, but can include:
- Appearance of small, multiple cysts on the ovary, enlarged ovaries
visible by ultrasound
- Irregular periods, infrequent menses or lack of menstruation
(amenorrhea) due to infrequent or absent ovulation
- Infertility and miscarriage
- Elevated blood levels of male hormones (androgens), especially
testosterone
- Adult acne /oily skin/seborrhea
- Excess facial and body hair (hirsutism)
- Male-pattern baldness, hair loss or thinning hair (alopecia)
- Weight problems especially around the midsection (central obesity)
- High blood pressure (hypertension)
- Abnormal lipid levels including elevated tricylercides and high
cholesterol
- Impaired glucose tolerance, insulin resistance, hyperinsulinemia,
& type II diabetes
- Skin tags (acrochordons) and dark velvety patches of thickened
and dark brown or black skin on the neck, arms, breasts, or thighs
(acanthosis nigricans)
- Chronic pelvic pain
- Sleep apnea (excessive snoring and breathing stops at times
while asleep)
Any or all of these symptoms may be present, but some women have none
of these symptoms and still can carry the diagnosis. These tend to
be very lean, athletic women who may be even underweight and this
may mask the PCO syndrome.
Diagnosis of PCOS
There is no single test to diagnose PCOS. A physician can often diagnose
PCOS by obtaining a detailed medical and gynecological history and
performing a physical exam. At the physical exam, evaluation of the
areas of increased hair growth will be important. During a pelvic
exam, the ovaries may be enlarged or swollen by the increased number
of small cysts. Blood hormone levels such as testosterone levels are
often measured to confirm the diagnosis. Additionally, glucose or
sugar levels, as well as insulin blood hormone levels may be measured.
A vaginal ultrasound may be performed to help distinguish PCOS from
other disorders that cause multiple cysts in the ovaries. The ultrasound
exam can also identify a thickened uterine lining. If menstrual periods
have been irregular or absent, an endometrial biopsy may be necessary
to rule out a pre-cancerous endometrial condition.
The current criteria for the diagnosis of PCOS include the following
three items:
- Irregular or absent periods
- Signs of excess androgens (male hormones) in the form of excess
hair growth or blood tests that show elevated levels of androgen
"
- Lack of any other conditions that would explain the above two
conditions, such as problems with the pituitary, thyroid or adrenal
glands
The combination of a detailed history, physical exam and blood testing
is usually adequate to diagnose PCOS. A genetic predisposition to
PCOS has been proposed. Women whose mothers had PCOS should watch
carefully for symptoms. Early diagnosis and treatment may decrease
the development of acne and hirsutism.
Health Problems Associated with PCOS
Although PCOS is primarily a problem of the ovaries, the condition
alters hormone levels and affects tissues throughout the body. Because
PCOS is not fully understood, it is often difficult to determine why
it is associated with a variety of health problems.
Weight gain and obesity - PCOS is
associated with gradual weight gain and obesity in about one-half
of the women with this condition. Obesity can aggravate PCOS. It is
thought that fatty tissues produce excess estrogen which can affect
the brain and result in insufficient secretion of FSH. Insufficient
FSH prevents ovulation and may worsen PCOS. Diet and exercise can
help maintain a normal body weight. For some women with PCOS, the
obesity develops at the time of puberty.
Insulin abnormalities and diabetes
- PCOS is also associated with abnormal blood insulin levels, the
hormone that regulates blood sugar levels. These abnormalities may
include:
- Hyperinsulinemia (excess production of insulin)
- Insulin resistance (poor response of body tissues to insulin)
- Impaired glucose tolerance (a condition of borderline diabetes
mellitus)
- Type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus,
a condition characterized by elevated blood sugar levels)
Insulin resistance and hyperinsulinemia can occur in both normal-weight
and overweight women with PCOS. By age 40, up to 35 percent of obese
women with PCOS develop impaired glucose tolerance, and up to 10 percent
of obese women with PCOS develop type 2 diabetes. These rates are
much higher than expected for normal women at this young age.
Impaired glucose tolerance and diabetes are usually detected by blood
tests. Often a fasting blood test is sufficient, but sometimes a glucose
tolerance test is needed. Weight loss, exercise, and drugs can help
normalize blood sugar levels.
Heart disease and hypertension- The
presence of both obesity and insulin resistance might increase a woman's
risk for coronary artery disease, which is the narrowing of the arteries
that supply blood to the heart. Both weight loss and treatment of
insulin abnormalities can decrease this risk.
Uterine cancer - Irregular menstrual
periods and the absence of ovulation cause women to produce the hormone
estrogen, but not the hormone progesterone. Without progesterone,
which causes the endometrium to shed each month as a menstrual period,
there is a hormonal imbalance. This promotes persistent growth of
the endometrium (the lining of the uterus). Eventually, this can lead
to endometrial hyperplasia or cancer. Treatment with oral contraceptives
or intermittent progesterone-like drugs can promote normal menstrual
bleeding and lessen overgrowth of the endometrium.
Sleep apnea - Sleep apnea has been
reported to occur in up to 30 percent of women with PCOS. This is
a disorder characterized by excessive snoring at night with brief
spells where breathing stops (apnea). Patients with this problem experience
fatigue and daytime sleepiness.
Hirsutism - Hirsutism is the excess
growth of coarse dark hair in a predominantly male pattern. Women
affected by PCOS commonly experience hirsutism due to increased levels
of the male hormones called androgens. The longer a woman with PCOS
goes untreated the more severe her hirsutism will become.
Infertility- Lack of ovulation or
infrequent ovulation results in difficulty in getting pregnant.
Most of these above mentioned effects can be anticipated and thus
prevented or promptly treated before they pose significant health
problems.
PCOS and Infertility
Women with PCOS generally have irregular, infrequent, or even absent
ovulation. Without ovulation there is no egg or ovum that is available
for fertilization. Also, due to the abnormal hormone levels, the endometrium,
or inside lining of the uterus, does not develop normally in women
with PCOS. Therefore, even if a rare ovulation was to occur and the
egg was fertilized, the endometrium may not be properly developed
to allow for the attachment and growth of the embryo.
The good news is that this problem with ovulation be fixed with medications.
These include ovulation induction agents, insulin sensitizing drugs
and Gonadotropins. Individual needs and response to therapy will usually
determine the appropriate medication. It is important to know that
these options work best for women who are not obese. Even a modest
amount of weight loss may improve the effectiveness of the medications.
Medications called ovulation induction agents, such as clomiphene
citrate stimulate the ovaries to release one or more eggs. Clomiphene
is simple to use and relatively cost- effective. Clomiphene citrate
interacts with the brain, causes an increase in FSH secretion and
works well to trigger ovulation in about 80 percent of women with
PCOS. About 50 percent of these women will actually become pregnant.
Approximately 10 percent of the pregnancies are twins while triplets
or more are rare. In women taking clomiphene, ovulation can be confirmed
by blood and urine tests or by measurement of body temperature. If
the original dose of clomiphene does not trigger ovulation, a higher
dose may help.
Several studies have shown that the insulin-sensitizing drug, metformin,
increases the effectiveness of clomiphene in producing ovulation.
However, it is unknown if this drug is safe during pregnancy, and
is stopped once the woman is pregnant.
Gonadotropin therapy is a second, more aggressive medical treatment
for PCOS-related infertility. If Clomiphene does not work within approximately
six cycles, gonadotropins namely, Leutinizing hormone (LH) and Follicle
Stimulating Hormone (FSH) may be used. This medication is more expensive
and has a higher incidence of side effects such as hyperstimulation
of the ovaries and multiple pregnancies. FSH is used without LH for
women with PCOS, and is given as a daily injection under the skin
for 7 to 10 days. These drugs trigger ovulation in almost all women
with PCOS and can lead to pregnancy in approximately 60 percent.
Surgery is an option in rare situations. In very rare cases, ovulation
is not achieved with medications and ovarian surgery may be necessary
to stimulate ovulation. This surgery is usually performed via the
laparoscope.
If the above mentioned treatments are not successful in producing
a normal pregnancy, then the use of the assisted reproductive technologies
(ART), such as in vitro fertilization, can be attempted.
In conclusion, a diagnosis of PCOS suggests that you are likely to
have some difficulty becoming pregnant. However, with help from your
physician, pregnancy should be an option for most patients with PCOS.
There appears to be a higher rate of miscarriage, gestational diabetes,
pregnancy-induced high blood pressure, and premature delivery in women
with PCOS. Preliminary studies also suggest that metformin might reduce
the risk of early pregnancy loss and the development of gestational
diabetes mellitus (diabetes during pregnancy) in women with PCOS,
while pregnant. Researchers are also looking at how the drug lowers
male hormone levels and limits weight gain in women who are obese
when they get pregnant. It is not yet known if Metformin usage is
safe during pregnancy, since the drug crosses the placenta.
Treatment of PCOS
There is no cure for PCOS, but it is manageable with medications,
diet, and exercise. Adequate treatment can help prevent serious long-term
risk factors. The treatment is relatively simple and based upon the
goals of the patient. Some patients may be concerned primarily with
fertility, while others may be more concerned about menstrual cycle
regulation, hirsutism or acne. Regardless of the primary goal, patients
are advised to report all symptoms to their physician as specifically
as possible.
Below are general descriptions of treatments used for PCOS:
- Birth control pills: For women
who don't want to become pregnant, birth control pills can regulate
menstrual cycles, reduce male hormone levels, and help to clear
acne. However, the birth control pill does not cure PCOS. The
menstrual cycle will become abnormal again if the pill is stopped.
A pill that only has progesterone can also regulate the menstrual
cycle and prevent endometrial problems. But progesterone alone
does not help reduce acne and hair growth. Birth control pills
are not recommended for women who smoke and are over the age of
35 years.
- Diabetes Medications: The medicine,
Metformin, also called Glucophage, which is used to treat type
2 diabetes, also helps with PCOS symptoms. Metformin affects the
way insulin regulates glucose and decreases the testosterone production.
Abnormal hair growth will slow down and ovulation may return after
a few months of use. These medications will not cause a person
to become diabetic.
- Fertility Medications: The main
fertility problem for women with PCOS is the lack of ovulation.
Even so, a sperm analysis should be performed and the tubes checked
to make sure they are open before fertility medications are used.
Clomiphene (pills) and Gonadotropins (shots) can be used to stimulate
the ovary to ovulate. If medications do not succeed in achieving
a pregnancy, In vitro Fertilization (IVF) is sometimes recommended.
Metformin can be taken with fertility medications and helps to
make PCOS women ovulate on lower doses of medication.
- Medication for increased hair growth
or extra male hormones: If a woman is not trying to get
pregnant there are some other medicines that may reduce hair growth.
Spironolactone is a blood pressure medicine that has been shown
to decrease the male hormone's effect on hair. Propecia, a medicine
taken by men for hair loss, is another medication that blocks
this effect. Both of these medicines can affect the development
of a male fetus and should not be taken if pregnancy is possible.
Other non-medical treatments such as electrolysis or laser hair
removal are effective at getting rid of hair. A woman with PCOS
can also take hormonal treatment to keep new hair from growing.
- Surgery: Although it is not recommended
as the first course of treatment, surgery called ovarian drilling
is available to induce ovulation. It is an option in very rare
cases. A very small incision IS made above or below the navel,
and a small instrument that acts like a telescope is inserted
into the abdomen. This is called laparoscopy. The doctor then
punctures the ovary with a small needle carrying an electric current
to destroy a small portion of the ovary. This procedure carries
a risk of developing scar tissue on the ovary. This surgery can
lower male hormone levels and help with ovulation. But these effects
may only last a few months. This treatment doesn't help with increased
hair growth and loss of scalp hair.
- Weight Loss: Maintaining a healthy
weight is another way women can help manage PCOS. Since obesity
is common with PCOS, a healthy diet and physical activity help
maintain a healthy weight, which will help the body lower glucose
levels, use insulin more efficiently, and may help restore a normal
period. Even loss of 10% of her body weight can help make a woman's
cycle more regular.
In summary, PCOS is a fairly common, defined syndrome for which no
cure exists. Treatment of the symptoms can help reduce risks of future
health problems. Today, several drugs and lifestyle modifications
can help control the signs and symptoms of PCOS. Medical and surgical
treatment can also help women who want to become pregnant, but are
having difficulty conceiving. Treatment is individualized and depends
on each woman's symptoms, reproductive goals, and presence of other
medical conditions. In some women, symptoms of PCOS may be minor and
simply annoying, and treatment may seem unnecessary. However, untreated
PCOS may increase a woman's risk of other health problems over time.
Women with PCOS should take an active role in their medical care by
learning as much as they can about the condition and by working with
their physician to develop the best treatment plan. Dealing with PCOS
can be emotionally difficult. Discussing all concerns with a physician
and exploring the medical and cosmetic treatments available to treat
PCOS as soon as possible is of vital importance. In the News Dr. Pinto
is privileged to be selected by his peers as one of the Best doctors
in Dallas, 2005 "Best Doctors in Dallas" D Magazine, October 2005
Recent Publications IVF-immature oocyte Letrozole and PCOS Leydig
cell tumor Sperm freezing.
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In the News |
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Pinto is privileged to be selected by his peers
as one of the Top Doctors in Texas,
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