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Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an

abnormal amount of androgens, male sex hormones that are usually present in women
in small amounts. The name polycystic ovary syndrome describes the numerous small
cysts (fluid-filled sacs) that form in the ovaries. However, some women with this
disorder do not have cysts, while some women without the disorder do develop cysts.

Ovulation occurs when a mature egg is released from an ovary. This happens so it can
be fertilized by a male sperm. If the egg is not fertilized, it is sent out of the body during
your period.

In some cases, a woman doesn’t make enough of the hormones needed to ovulate.
When ovulation doesn’t happen, the ovaries can develop many small cysts. These cysts
make hormones called androgens. Women with PCOS often have high levels of
androgens. This can cause more problems with a woman’s menstrual cycle. And it can
cause many of the symptoms of PCOS.

Treatment for PCOS is often done with medication. This can’t cure PCOS, but it helps
reduce symptoms and prevent some health problems.

What causes PCOS?


The exact cause of PCOS is not clear. Many women with PCOS have insulin
resistance. This means the body can't use insulin well. Insulin levels build up in the body
and may cause higher androgen levels. Obesity can also increase insulin levels and
make PCOS symptoms worse.

PCOS may also run in families. It's common for sisters or a mother and daughter to
have PCOS.

What are the risks for PCOS?


You may be more likely to have PCOS if your mother or sister has it. You may
also be more likely to have it if you have insulin resistance or are obese.

What are the symptoms of PCOS?


The symptoms of PCOS may include:

• Missed periods, irregular periods, or very light periods


• Ovaries that are large or have many cysts
• Excess body hair, including the chest, stomach, and back (hirsutism)
• Weight gain, especially around the belly (abdomen)
• Acne or oily skin
• Male-pattern baldness or thinning hair
• Infertility
• Small pieces of excess skin on the neck or armpits (skin tags)
• Dark or thick skin patches on the back of the neck, in the armpits, and under the
breasts

How is PCOS diagnosed?


Your health care provider will ask about your medical history and your symptoms. You
will also have a physical exam. This will likely include a pelvic exam. This exam checks
the health of your reproductive organs, both inside and outside your body.

Some of the symptoms of PCOS are like those caused by other health problems.
Because of this, you may also have tests such as:

• Ultrasound. This test uses sound waves and a computer to create images of
blood vessels, tissues, and organs. This test is used to look at the size of the
ovaries and see if they have cysts. The test can also look at the thickness of the
lining of the uterus (endometrium).
• Blood tests. These look for high levels of androgens and other hormones. Your
health care provider may also check your blood glucose levels. And you may
have your cholesterol and triglyceride levels checked.

How is PCOS treated?


Treatment for PCOS depends on a number of factors. These may include your age,
how severe your symptoms are, and your overall health. The type of treatment may also
depend on whether you want to become pregnant in the future.

If you do plan to become pregnant, your treatment may include:

• A change in diet and activity. A healthy diet and more physical activity can
help you lose weight and reduce your symptoms. They can also help your body
use insulin more efficiently, lower blood glucose levels, and may help you
ovulate.
• Medications to cause ovulation. Medications can help the ovaries to release
eggs normally. These medications also have certain risks. They can increase the
chance for a multiple birth (twins or more). And they can cause ovarian
hyperstimulation. This is when the ovaries release too many hormones. It can
cause symptoms such as abdominal bloating and pelvic pain.

If you do not plan to become pregnant, your treatment may include:

• Birth control pills. These help to control menstrual cycles, lower androgen
levels, and reduce acne.
• Diabetes medication. This is often used to lower insulin resistance in PCOS. It
may also help reduce androgen levels, slow hair growth, and help you ovulate
more regularly.
• A change in diet and activity. A healthy diet and more physical activity can
help you lose weight and reduce your symptoms. They can also help your body
use insulin more efficiently, lower blood glucose levels, and may help you
ovulate.
• Medications to treat other symptoms. Some medications can help reduce
hair growth or acne.

What are the complications of PCOS?


Women with PCOS are more likely to develop certain serious health problems. These
include type 2 diabetes, high blood pressure, problems with the heart and blood
vessels, and uterine cancer. Women with PCOS often have problems with their ability to
get pregnant (fertility).

Living with PCOS


Some women struggle with the physical symptoms of PCOS, such as weight gain, hair
growth, and acne. Cosmetic treatments, such as electrolysis and laser hair removal,
may help you feel better about your appearance. Talk with your health care provider
about the best ways to treat the symptoms that bother you.

When should I seek medical care?


If you have missed or irregular periods, excess hair growth, acne, and weight gain, call
your doctor for an evaluation.

Key points
• PCOS is a very common hormone problem for women of childbearing age.
• Women with PCOS may not ovulate, have high levels of androgens, and have
many small cysts on the ovaries.
• PCOS can cause missed or irregular menstrual periods, excess hair growth,
acne, infertility, and weight gain.
• Women with PCOS may be at higher risk for type 2 diabetes, high blood
pressure, heart problems, and endometrial cancer.
• The types of treatment for PCOS may depend on whether or not a woman plans
to become pregnant. Women who plan to become pregnant in the future may
take different kinds of medications.
• Polycystic ovary syndrome (PCOS) is a common, heterogeneous condition of ovarian
dysfunction in women during their reproductive years. It is often associated with chronic
anovulatory infertility and hyperandrogenism.1 The incidence of this condition can be up to
20%. However, this may vary according to ethnicity. For example, there is a higher
prevalence of PCOS among South East Asian women and they generally have more severe
symptoms. PCOS can be diagnosed in up to 10% of women attending gynaecology
outpatient clinics. However, the incidence may be much higher. Diagnosis rates depend on
which criteria are used.
• PCOS is often associated with hirsutism or acne, infertility, weight gain, endometrial
hyperplasia, as well as an increased risk of type 2 diabetes and cardiovascular disease.2
• PCOS commonly presents with oligomenorrhoea, hirsutism and acne. Women with PCOS
who have a raised BMI have a greater long-term risk of impaired glucose tolerance, type 2
diabetes, dyslipidaemia and sleep apnoea than those without PCOS.3
• The aetiology of PCOS is unknown. Recent evidence has suggested that insulin resistance
resulting in excess androgen production by the ovaries may be responsible. It is thought that
elevated levels of luteinising hormone (LH) can lead to overstimulation of ovarian theca cells
in PCOS, which in turn may cause excessive androgen production. A family history of PCOS
may be relevant.4
• Diagnosis
Symptoms of PCOS may present at puberty or later in a woman's reproductive years.
• A woman with PCOS may present with acne or hirsutism. If there has been rapid hair growth,
a neoplastic cause of androgen production needs to be considered.
• Hyperandrogenism in PCOS may present with excess terminal body hair in a male
distribution pattern. For example, excess hair on the upper lip, chin and around the nipples.
Some women may experience male-pattern hair loss. Women may present with irregular
periods or subfertility. Despite irregular menstrual cycles, most women with PCOS do
ovulate.1
• The Rotterdam European Society for Human Reproduction and Embryology (ESHRE) and
the American Society of Reproductive Medicine (ASRM) PCOS Consensus Workshop
suggests that PCOS can be diagnosed if two of the following criteria are met: polycystic
ovaries, oligo- or anovulation, or clinical or biochemical signs of hyperandrogenism.5 PCOS
is diagnosed if other potential causes such as thyroid disorders, congenital adrenal
hyperplasia, hyperprolactinaemia, androgen-secreting tumours and Cushing syndrome have
been excluded.6 For example, in women presenting with oligo- or anovulation an assessment
of serum follicle-stimulating hormone (FSH) and oestradiol may be helpful to exclude a
central cause of ovarian dysfunction (hypogonadotrophic hypogonadism) or premature
ovarian failure.6
• Polycystic ovaries may be diagnosed by identifying 12 or more peripheral follicles measuring
2–9mm in diameter and/or increased ovarian volume on ultrasonography. In the past, an
elevated LH to FSH ratio was considered supportive of a diagnosis of PCOS. It is now
thought that a measurement of serum gonadotrophins is less useful from a diagnostic point
of view. Insulin resistance and elevated LH levels are common features in PCOS.
• Investigations for PCOS include thyroid function tests, serum prolactin, free androgen index
and serum gonadotrophins. Sex hormone binding globulin levels are usually low in PCOS. If
total testosterone is greater than 5nmol/l and there is clinical evidence of hyperandrogenism,
17-hydroxyprogesterone should be sampled and androgen-secreting tumours excluded.6

Self-test scenario

Case history A 32-year-old woman with PCOS attends the GP surgery with a newspaper article on PCOS and the
risk of developing diabetes. Her mother has type 2 diabetes. The woman is concerned about her risk of developing
diabetes and requests testing.
Q: What advice would you give her?
A: Patients with PCOS that have a BMI >25 kg/m2 should be offered screening for type 2 diabetes. Those with a BM
<25 who have risk factors such as a family history of type 2 diabetes and/or a history of gestational diabetes should
offered an oral glucose tolerance test. An assessment should be made of cardiovascular risk factors such as smokin
diet and exercise. In those with impaired fasting glycaemia or impaired glucose tolerance, a glucose tolerance test
should be offered on an annual basis. In women who have been diagnosed before pregnancy with PCOS, screening
for gestational diabetes may be considered at 24 to 28 weeks.

• Management
• Women with anovulatory infertility are at risk of developing endometrial hyperplasia, which
may be premalignant. It is good practice to recommend treatment with progestogens to
induce a withdrawal bleed at least every three to four months.6 No additional surveillance is
required. If a woman does not wish to conceive, the combined oral contraceptive pill is
frequently used to regulate irregular cycles and slow hair growth.
• The combined oral contraceptive pill increases sex hormone binding globulin levels, which
results in a reduction in free testosterone. LH and FSH levels are suppressed. Pregnancy
must be ruled out before oral contraceptive therapy is started. An
oral contraceptive containing oestradiol and a progestogen with minimal androgenic activity,
such as norgestimate should be considered. Yasmin (ethinyl oestradiol combined with
drospirenone) has a progestogen that acts as an anti-androgen. Progestogens alone may be
used to induce bleeding in the latter part of menstrual cycles. However, this does not
provide contraceptive cover or reduce the skin manifestations of PCOS.6
• Anti-androgens such as spironolactone can be used to reduce hair growth. If this is being
considered contraceptive cover is important. Spironolactone prevents dihydrotestosterone
binding to its receptor at the hair follicle. It is also a diuretic. The beneficial effect of this
therapy may not be apparent until three months after starting treatment, and the effect can
be reversible on discontinuation of the anti-androgen.
• Hirsutism and/or acne may be controlled by a combination of ethinyl oestradiol and
cyproterone acetate (Dianette) for three to four months. Eflornithine is a topical application
that inhibits ornithine decarboxylase, thereby reducing hair growth. Other non-
pharmacological treatments for hirsutism include: shaving, waxing, electrolysis, intense
pulsed light and laser therapy.6
• Women diagnosed with PCOS should be advised regarding weight control and exercise as
this improves insulin sensitivity and reduces the risk of metabolic syndrome.5,6 Diet and
exercise may reduce free testosterone levels and increase sex hormone binding globulin,
which improves hirsutism. Lifestyle modifications also improve menstrual irregularity.5
• Psychological comorbidity should be considered in patients with PCOS, as anxiety or
depression can coexist. Psychological sequelae may result from hirsutism or acne, as well
as possible infertility.
• Women presenting with PCOS, particularly if they have a BMI greater than 30, have a family
history of type 2 diabetes or over 40 years of age are at increased risk of type 2 diabetes.
Therefore, these women should be offered a glucose tolerance test and serum lipids to
screen for the risk of metabolic syndrome.7 There is a higher risk of gestational diabetes in
women with PCOS.
• Metformin decreases gluconeogenesis and increases peripheral utilisation of glucose. It may
be recommended for women with PCOS in some clinical situations. However, metformin use
for PCOS is unlicensed.7
• Women with PCOS should be asked about snoring and daytime somnolence due to the
increased risk of sleep apnoea in women with PCOS.5
• Women with PCOS and subfertility may benefit from weight loss as this can increase the
chances of ovulatory cycles. Specialist referral may be required for further management.
Additionally, weight loss improves the effectiveness of infertility treatment.

Polycys'c Ovary Syndrome (PCOS) affects 15%–


20% of adolescents and women of childbearing
age.
It is a result of androgen excess and leads to the progression of several endocrine,
metabolic, cardiovascular, reproductive, and psychological disorders. The increased
androgen levels may be due to the underlying hormonal imbalance and insulin
resistance that is involved in PCOS.1

PCOS appears to be a congenital disorder with signs and symptoms starting as early as
puberty. The primary cause of the excess androgen levels (male hormones) seen with
PCOS is unknown; however, there appears to be recurrence in families. Many of these
clinical manifestations occur in puberty and have a long-term impact on an adolescent’s
or woman’s daily wellbeing and activities of daily living.2

Anti-Mullerian Hormone (AMH) increases in women with PCOS and affects


follicogenesis. AMH levels should decrease when follicles enlarge, but when levels
remain high, follicles do not mature and ovulation is affected. Increased androgen levels
cause a decrease in progesterone and estrogen, leading to a hypersecretion of
gonadotropic-releasing hormone (GnRH) and luteinizing hormone (LH) levels, which
continues to stimulate immature follicles which do not mature and form cysts in the
ovary.3
Most adolescents reported that primary symptoms associated with PCOS such as acne,
obesity, hirsutism, infertility, and menstrual problems had the most negative impact on
their lives. These symptoms caused mood fluctuations and affected personal
relationships.4 Adolescents and women of childbearing age will visit numerous clinicians
before being diagnosed with PCOS, and 50% to 75% of those adolescents and women
will present to the primary care provider with already existing clinical manifestations of
PCOS.5

Clinical Features

Diagnosis of PCOS in adolescents is problematic because symptoms such as irregular


menses, acne, and weight gain seen in adolescent girls are considered part of normal
growth and development for this age group. For this age group, the most common
diagnostic criteria used is increased androgen levels.5 In adolescents and women of child
bearing age, the most common diagnostic criteria used for PCOS are evidence of
increased androgen levels, anovulatory symptoms such as amenorrhea, menorrhagia,
oligomenorrhea, infertility, and/or polycystic ovaries.

Other clinical features that alert clinicians to the possibility of PCOS include:

• Hirsutism
• Acne
• Androgenic alopecia (hair loss);
• and Acanthosis Nigricans.

Early pubarche in girls (8.73 vs. 10.73 years) and early thelarche (breast development
8.76 vs. 10.27 years) were early indicators of increased androgen levels and an increased
likelihood of having PCOS. The most common disorders linked to PCOS include
diabetes, cardiovascular disorders, reproductive disorders, cancer risks, and
psychological disorders. PCOS is a heterogeneous disorder (not all patients show all
symptoms of the disease.1

Diabetes

More than 50 percent of women with PCOS in the United States are obese (body mass
index > 30 kg/m3), a similar rate to that of obesity in the United States.7 Most of these
women have an increased amount of adipose tissue in the central body region. Obesity
in women with PCOS causes increased androgen levels, insulin resistance, cardiovascular
risks, and infertility. Insulin resistance and abnormal glucose metabolism seen in these
women can lead to the development of type 2 diabetes.

At least 10% of women with PCOS will develop diabetes, a risk attributed to obesity,
which increases glucose intolerance and insulin resistance over time.8 Insulin resistance
occurs in about 50% to 80% of obese women with PCOS. Lean women with PCOS have
lessened insulin resistance.9

Cardiovascular Disorders

In addition to diabetes risk, women with PCOS have increased cardiovascular risk. These
women have increased clinical and subclinical markers for atherosclerosis such as
increased coronary artery calcification and carotid plaque, which is exacerbated by
obesity.10 Women with PCOS are four times more likely to develop metabolic syndrome
than women who do not have PCOS. Metabolic syndrome involves physical and
biochemical abnormalities that include elevated blood pressure (>or = 130/85),
increased waist circumference (> or = 35 inches), elevated fasting glucose levels (> or =
100 mg/mg/dl), decreased high density lipoprotein cholesterol levels (< or = 50 mg/d),
and elevated triglyceride levels (> or = 150 mg/dl). This syndrome is linked to an
increased risk of cardiovascular disease and stroke.11

Reproductive Disorders

PCOS is the most common cause of anovulation and infertility in women. Central
abdominal obesity causes increased androgen levels and insulin resistance, inhibiting
ovarian follicle development and maturation leading to anovulation symptoms such as
menstrual irregularities and infertility. As little as 5% weight loss can lower androgen
levels and resume menses.13 PCOS accounts for 90% to 95% of women attending
infertility clinics due to anovulatory symptoms. About 60% of these women are fertile
(able to conceive in 12 months). Most women with PCOS and infertility will need
assisted reproductive technologies to successfully achieve pregnancy. Pregnancy causes
perinatal complications such as spontaneous abortion, gestational diabetes, and
preterm birth.14

Cancer Risks

Long-term anovulation and increased unopposed estrogen lead to uterine hyperplasia


over time. The increased unopposed estrogen occurs because the ovarian follicles do
not mature and are not released to form progesterone to oppose high levels of
estrogen. Estrogen levels remain high and lead to irregular menses, or prolonged
bleeding from a buildup of the uterine lining by all the estrogen. Some of the excess
estrogen is converted to testosterone which can cause increased appetite levels and
lead to obesity.15 Women with PCOS have a significantly higher risk of developing
endometrial and ovarian cancer compared to women who do not have PCOS.16

Psychiatric Disorders

In addition to biological and physical problems, women with PCOS have increased risk
for psychological problems as well. Documented psychological problems include:

• Anxiety
• Depression
• Poor self-esteem
• Psychosexual dysfunction
• Bipolar disorder

These psychological problems could be attributed to clinical features such as hirsutism,


obesity, acne, and infertility, which can negatively affect mood and psychological well-
being.17 Women with PCOS had a 4- fold increase in depressive scores compared to the
control group.18

Treatment

Treatment for women with PCOS can be complex. The first step in treating these women
is to schedule a consultation with a primary care physician experienced with the
condition or a reproductive endocrinologist. Weight reduction in obese women is a
commonly supported intervention. Women are advised to reduce caloric intake and
exercise to achieve at least a 5 percent weight loss. Weight reduction is most beneficial
to those women showing signs of metabolic syndrome. In addition, these women will
need insulin-sensitizing agents, such as metformin and lipid-lowering agents such as
statins as needed. Bariatric surgery may be prescribed for those that are morbidity
obese.19,20

Treatment of high androgen related symptoms include oral contraceptive pills,


antiandrogens (spironolactone), acne treatments, and laser hair removal treatments.
Progestin-only contraceptives may be prescribed to prevent uterine hyperplasia, but
may cause abnormal bleeding. Women with PCOS and infertility should be referred to a
reproductive endocrinologist to discuss treatment options to achieve pregnancy. Risks
associated with the various ovulatory induction medications should be discussed such as
ovarian hyperstimulation and multiple births. Clomid is the first-line ovulation induction
medication that is prescribed. Second-line ovulatory medication is injectable
gonadotropins. Laparoscopic ovarian surgery (ovarian drilling) is a surgical treatment
option that can regulate menses and trigger ovulation in women with PCOS. This
procedure involves use of a laser fibre or electromagnetic needle to puncture the ovary
four to ten times.

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