Polycystic Ovary Syndrome
Polycystic Ovary Syndrome
Understanding ovaries and ovulation
The ovaries are a pair of glands that lie on either side of the uterus (womb). Each ovary is about the size of a large marble. The ovaries make ova (eggs) and various hormones. Hormones are chemicals that are made in one part of the body, pass into the bloodstream, and have an effect on other parts of the body.
- Ovulation means egg production. This normally occurs once a month when you release an ovum (egg) into the fallopian tube which is attached to the uterus (womb). Before an ovum is released at ovulation, it develops within a little fluid filled sac called a follicle (tiny cyst). Each month several follicles start to develop, but normally just one fully develops and then gets released.
- The main hormones that are made in the ovaries are oestrogen and progestogen – the main ‘female’ hormones. These hormones help with the development of breasts, and also control the menstrual cycle. The ovaries also normally make small amounts of ‘male’ hormones (androgens) such as testosterone.
What is PCOS? – Picture of polycystic ovaries
Polycystic ovary syndrome (PCOS), formerly known as the Stein-Levanthal syndrome, is a condition where at least two of the following occur, and often all three:
- At least 12 follicles (tiny cysts) develop in your ovaries. (Polycystic means ‘many cysts’.)
- The balance of hormones that you make in the ovaries is altered. In particular, your ovaries make more testosterone (male hormone) than normal. When male hormones are increased, you often tend to get pimples, have excess hair growth on the face(upper lip/chin) and also lose scalp hair.
- You do not ovulate each month. Some women do not ovulate at all. (In PCOS, although the ovaries usually have many follicles, they do not develop fully and so ovulation often does not occur.) If you do not ovulate then you do not have a period every month. Most women with PCO have infrequent, irregular periods.
How common is PCOS?
PCO is very common problem. Research studies of women who had an ultrasound scan of their ovaries found that up to 1 in 4 young women have polycystic ovaries (ovaries with many small cysts). However, many of these women were healthy, ovulated normally, and did not have high levels of male hormones.
It is thought that up to 1 in 10 women have polycystic ovary syndrome (PCOS) – that is, at least two of: polycystic ovaries, a raised level of male hormone, reduced ovulation. However, these numbers may be higher.
What causes PCOS?
The exact cause is not totally clear. Several factors probably play a part. These include the following:
Insulin is a hormone that you make in your pancreas (a gland behind your stomach). The main role of insulin is to control your blood sugar level. Insulin acts mainly on fat and muscle cells causing them to take in sugar (glucose) when your blood sugar level rises. Another effect of insulin is to act on the ovaries to cause them to produce testosterone (male hormone).
Women with PCOS have what is called ‘insulin resistance’. This means that cells in the body are resistant to the effect of a normal level of insulin. More insulin is produced to keep the blood sugar normal. This raised level of insulin in the bloodstream is thought to be the main underlying reason why PCOS develops. It causes the ovaries to make too much testosterone. A high level of insulin and testosterone interfere with the normal development of follicles in the ovaries. As a result, many follicles tend to develop but often do not develop fully. This causes problems with ovulation: hence period problems and reduced fertility.
It is this increased testosterone level in the blood that causes excess hair growth on the body and loss of the scalp hair.
Increased insulin also contributes towards weight gain.
Luteinising hormone (LH)
The hormone – LH is made in the brain. It makes the ovaries produce eggs and also increases the production of male hormone – testosterone. A high level of LH is found in about 4 in 10 women with PCOS. A high LH level combined with a high insulin level means that the ovaries are likely to produce too much testosterone.
Your genes are also important. One or more genes may make you more prone to develop PCOS. PCOS may run in some families and often sisters tend have PCOS. Males who have the PCO gene can have early baldness and oily skin.
Being overweight or obese is not the underlying cause of PCOS. However, if you are overweight or obese, excess fat can make the symptoms worse. Women with PCOS tend to have fat accumulation in their tummy- appearing ‘apple shaped’. This is called central obesity. Losing weight, although difficult, can help improve symptoms and help the establishment of regular periods.
What are the symptoms and problems of PCOS?
These occur in about 7 in 10 women with PCOS. You may have irregular or light periods, or no periods at all.
You need to produce an egg each month to become pregnant. Women with PCOS may not ovulate each month, and some women do not ovulate at all. PCOS is one of the commonest causes of not being able to conceive.
Effects of too much male hormone
- Excess hair growth occurs in more than half of women with PCOS. It is mainly on the face, lower abdomen, and chest. This is the only symptom in some cases.
- Acne ( pimples) may persist beyond the normal teenage years.
- Loss of scalp hair (similar to ‘male pattern baldness’) occurs in some cases.
- Weight gain – about 4 in 10 women with PCOS become overweight or obese.
- Depression or poor self esteem may develop as a result of the other symptoms.
Symptoms typically begin in the late teens or early 20s. Not all symptoms occur in all women with PCOS. For example, some women with PCOS have some excess hair growth, but have normal periods and fertility. Symptoms may also change over the years. For example, acne may become less of a problem in middle age, but hair growth may become more noticeable.
Possible long-term problems of PCOS
If you have PCOS, over time you have an increased risk of developing type 2 diabetes, diabetes in pregnancy, a high cholesterol level, and possibly high blood pressure. For example, about 1 in 10 women with PCOS develop diabetes at some point. These problems in turn may also increase your risk of having a stroke and heart disease in later life.
If you have no periods, or very infrequent periods, you may have a higher than average risk of developing cancer of the uterus (womb).This risk is however small.
Are any tests needed?
Tests may be advised to clarify the diagnosis, and to rule out other hormone conditions.
- Blood tests may be taken to measure certain hormones. For example, a test to measure testosterone and LH which tend to be high in women with PCOS.
- An ultrasound scan of the ovaries may be advised. An ultrasound scan is a painless test that uses sound waves to create images of structures in the body. The scan can detect the typical appearance of PCOS with the many follicles (small cysts) in slightly enlarged ovaries.
Also, you may be advised to have regular checks of blood sugar, blood pressure, and blood cholesterol to detect any abnormality as early as possible. Exactly when and how often the checks are done depends on your age, your weight, and other factors. After the age of 40, these tests are usually recommended every year.
What is the treatment for PCOS?
There is no cure for PCOS. We cannot replace your polycystic ovaries with normal ovaries. However, symptoms can be treated, and your health risks can be reduced.
Losing weight helps to reduce the high insulin level that occurs in PCOS. This has a knock-on effect of reducing male hormones. This then improves the chance of you producing an egg and also improves any period problems, you chance of conceiving and may also help you to reduce hair growth and acne. The increased risk of long-term problems such as diabetes, high blood pressure, etc, are also reduced.
Losing weight can be difficult. A combination of eating less and exercising more is best. Advice from a dietician, and help and support from a practice nurse, may increase your chance of losing weight. Even a moderate amount of weight loss can help.
Treating hair growth
Hair growth is due to the increased level of testosterone – the ‘male’ hormone.
- Unwanted hair can be removed by shaving, waxing, hair removing creams, electrolysis, and laser treatments. These need repeating every now and then, although electrolysis and laser treatments may be more long lasting .
- A cream called eflornithine may be prescribed to rub on affected areas of skin. It works by counteracting an enzyme (chemical) involved in making hair in the skin. Some research trials suggest that it can reduce unwanted hair growth, although this effect quickly wears off after stopping treatment. It is called vaniqua cream
Drugs taken by mouth can also treat hair growth. They work by reducing the amount of testosterone that you make, or by blocking its effect. Drugs include:
- The combined contraceptive pill – Novelon. There are many pills to choose from, but all have some effect of reducing hair growth.
- Cyproterone acetate is an ‘antitestosterone’ drug. This is commonly combined with oestrogen as a special contraceptive pill called Krimson 35. Krimson 35 is commonly prescribed to regulate periods, to help reduce hair growth, to reduce acne, and is a good contraceptive.
Tablets taken by mouth to treat hair growth take 3-9 months to work fully. You need then to carry on taking them otherwise hair growth will recur. Removing hair by the methods above (shaving etc) may be advised whilst waiting for a tablet to work.
The tablet Krimson 35 will reduce pimples. But if the problem is too severe, you may get additional advice from a skin specialist.
Treating period problems
Some women who have no periods, or infrequent periods, do not want any treatment for this. However, your risk of developing cancer of the uterus (womb) may be increased if you have no periods for a long time. Therefore you must have a period at least once every two months.
Therefore, some women with PCOS are advised to take the contraceptive pill as it causes regular ‘withdrawal bleeds’ similar to periods. If this is not suitable, another option is to take progestogen hormone for five days every month which will cause a monthly bleed like a period.
Problems with getting pregnant
The chance of becoming pregnant depends on how often you ovulate. Some women with PCOS ovulate now and then, others not at all.
If you do not ovulate but want to become pregnant, then fertility treatments may be recommended by a specialist and have a good chance of success. But remember, you are much less likely to become pregnant if you are obese. If you are obese or overweight then losing weight is advised in addition to other fertility treatments.
There are many medicines which can be given if you wish to get pregnant. For further details please read the booklet on Ovulation induction
Preventing long term problems
A healthy lifestyle is important to help prevent the conditions listed above in ‘long-term problems’. For example, you should: eat a healthy diet, exercise regularly, lose weight if you are overweight or obese, and not smoke. For advice on food, please contact any of our staff.
Summary of Polycystic Syndrome PCOS
Polycystic ovary syndrome (PCOS) is common. It can cause period problems, reduced fertility, excess hair growth, and acne. Many women with PCOS are also overweight. Treatment includes weight loss (if you are overweight), and lifestyle changes in addition to treating the individual symptoms.
Dr. Vani Sundarapandian
Medical Director, Jananam Fertility Center