Polycystic Ovarian Syndrome
Polycystic ovarian syndrome
(PCOS), also called Stein-Leventhal Syndrome, is the most common
endocrinologic disorder in women of reproductive age.
 Approximately
5-10% of reproductive age women have PCOS. This syndrome can have many
symptoms. However, the two key components defining this disorder must include
chronic anovulation (inability to ovulate an egg) and clinical hyperandrogenism
(elevated male type hormones). The reason for multiple cyst development is not
clear, but appears to be related to instrinsic insulin resistance demonstrated
in women with PCOS. In comparison to normal ovulation, women with PCOS are not
able to completely develop a fully mature egg on their own, and therefore the
ovulatory process in not completed.
Polycystic Ovarian Syndrome is
comprised of several clinical features, each of which may be present to a
greater or lesser degree. The various symptoms of PCOS can be irregular or
absent menstrual cycles, infrequent or absent ovulation, excess facial and body
hair, male pattern balding, acne of face/back/chest, and infertility. Other
findings can include an elevated FSH to LH hormone ratio, elevated levels of
male hormones, multiple small cysts of the ovaries and elevated cholesterol.
Some women have been found to have polycystic ovaries without associated
abnormalites of menstruation, hair growth or fertility.
Because PCOS
encompasses such a broad spectrum of signs and symptoms, diagnosis can be
frustratingly difficult. In 2003, an international consensus expanded the
definition of PCOS to include women who demonstrate two of the three following
conditions: irregular or absent ovulation, elevated levels of androgenic (male)
hormones, and/or polycystic ovaries on ultrasound. Many but not all women with
PCOS have enlarged ovaries with many small cyst (fluid-filled sacs) that are
visible on ultrasound, a finding that can also be seen in approximately 20 % of
women with normal menstrual cycles.
The lack of ovulation in women
with PCOS results in a continous exposure of the lining of the uterus or
endometrium to estrogen. This causes excessive thickening of the endometrium
and may cause heavy, irregular bleeding. Over years, endometrial cancer may
result due to this continous stimulation.
The causes of PCOS are
unknown. Driving the abnormal levels of ovarian hormones in PCOS women is an
elevation of the hormone insulin. Additionally, this imbalance contributes to
an excess of male hormone production by the ovaries, which can be worsened by
insulin resistance. There is no cure for PCOS, though the various symptoms
can be addressed and managed, and therefore help reduce the risk of long-term
health consequences.
If you are diagnosed with PCOS, treatment
will depend upon your goals. Dealing with PCOS can be emotionally difficult.
Women with PCOS may feel self conscious about their excessive hair growth or
weight, as well as their inability to have children. If fertility is the
primary concern, then ovulation is induced through orally adminstered
medications.
If fertility is not an immediate concern, hormonal
therapies often correct the problems associated with PCOS. Medications commonly
used include birth control pills, which may reduce the hirsutism (excessive
hair growth) and regulate menstrual cycles, and are often combined with other
medications such as spironolactone and Vaniqa cream to reduce body and facial
hair.
For overweight women, simply losing 10-15% of total weight
may be enough to allow spontaneous ovulation to occur. Weight loss is
associated with lowered androgen effects, less insulin resistance, an improved
lipid profile, and resumption of ovulatory function. Exercise is also an
important component of treatment and has been shown to resume ovulation and
increase chances for pregnancy.
Prior to starting treatment, it is
recommended that other factors which may be responsible for irregular cycles be
evaluated. This includes ruling out a thyroid disorder or elevated prolactin
which may cause irregular menstrual cycles. In cases where ovulation is
irregular or absent, drugs such as clomid (Clomiphene Citrate) can be used, as
well as insulin sensitizing drugs such as Metformin.
Studies
with Metformin indicate that most women with PCOS will spontaneously ovulate
after 3 months of treatment, or if not ovulatory, will become Clomid
"sensitive". One must be carefully screened prior to a course of Metformin, and
must be monitored during treatment. Side effects are mostly gastrointestinal
(nausea, vomiting, diarrhea). We frequently start metformin at a dose of 500 mg
per day for one week working up to a total dose of 2000 mg per day. If
gastrointestinal side effects develop, we can try using a long-acting form of
metformin which has a lower incidence of these side effects.
If
fertility medications are required, the first and simplest step is to use
Clomid (Clomiphene Citrate).
 The
starting dose is usually 50 mg, which may be progressively increased. Ovulation
is documented with a progesterone level obtained in the luteal phase of the
cycle to confirm ovulation. If ovulation is not achieved with a dose of 200
mg/day, then other strategies have to be investigated. If clomiphene fails to
successfully induce ovulation, then a group of injectable preparations, known
as gonadotropins may be used. Gonadotropins are
administered to stimulate the growth of one or two eggs, being careful not to
stimulate the growth of too many eggs. Follicular growth and development is
carefully monitored by hormone measurements and ultrasound examinations. If
monitoring shows that too many follicles are developing, and the risk of
multiple pregnancy is high, then the treatment will be cancelled.
In Vitro Fertilization
(IVF) is used when other treatment strategies have failed. This
treatment is used to reduce the risk of multiple gestation that can occur with
gonadotropins and
intrauterine
insemination. IVF is also used when pregnancy
has not occurred with any other means.
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Texarkana, TX 75503
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