By: Sue Ellen Carpenter, MD, FACOG, ACRM
Polycystic Ovarian Syndrome (PCOS) is a medical condition, present in 4 to 12% of the female population. PCOS is characterized by irregular menstrual cycles and elevated androgen (“male-type”) hormone levels. Women with PCOS rarely ovulate on their own, which is the cause of their infrequent periods, and may also have acne and/or facial and body hair caused by the increased androgens. Failure to ovulate regularly often leads to infertility in women with PCOS.
The specific symptoms experienced by any individual woman are determined by her ethnic and genetic background as well as the severity of her hormonal abnormalities. Thus, the presentation of polycystic ovarian syndrome can vary widely. As a result, patients may seek medical advise to correct irregular menstruation, reduce excessive hair growth and acne or to achieve pregnancy. Although 15% of women with PCOS are lean, many women with PCOS have difficulty with weight gain and benefit from nutritional guidance and increased exercise. ACRM's nutritionist, Paige Espenship, is skilled in advising women with PCOS on approaches that are specific to their situation.
The diagnosis of PCOS is made on the basis of the clinical history, androgen hormone levels (or signs and symptoms of high androgen levels) and with pelvic ultrasound for polycystic ovarian morphology. The ovarian follicle is the tiny “cyst” that forms around each egg. Typically, women with PCOS will have an increase in the number of small follicles (more than 12 per ovary) as measured by vaginal ultrasound. Often the follicles are arranged around the edges of the ovary like a “strand of pearls” around a central solid ovarian stroma. AMH (anti-mullerian hormone) is a blood test that can be used to confirm the tendency toward PCOS. The numerous tiny follicles present in PCOS are associated with higher than normal AMH levels.
The laboratory evaluation for PCOS is used to exclude other diagnoses that can cause irregular menses or hirsuitism: such as thyroid disorders, adrenal disorders and high prolactin levels. Estradiol, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are evaluated to rule out other ovarian abnormalities.
There is an association between high insulin levels, adult onset diabetes and PCOS. Woman with PCOS are screened for diabetes and high insulin levels by having a glucose tolerance test. High cholesterol levels are associated with PCOS, so women should have an annual lipid panel.
Treatment for PCOS varies of the course of a woman's reproductive life. Working to maintain ideal body weight is always important. When pregnancy is not desired, oral contraceptive pills help to manage menses and control high androgen levels. Anti-androgen medications (such as spironolactone) can be added to birth control pills to suppress androgenic symptoms such as excess hair growth and acne.
When women wish to conceive, ovulation induction is carried out using oral medications: clomid or letrozole. Insulin-sensitizing medications such as metformin or glucophage are often added to improve the efficacy of the fertility medications. Monitoring of ovulation with ultrasound, blood work, home ovulation predictor kits and progesterone levels, helps women to gain an understanding of how their ovaries are responding.
If oral medication is ineffective, the use of gonadotropin injections (injectable fertility medications FSH and LH with brand names such as bravelle, follistim and menopur) can be considered. This is safest and most effective in the setting of in vitro fertilization. The use of injectable medication is associated with higher order multiple pregnancy (triplets or more) and ovarian over-stimulation. These effects are mitigated in IVF where we can control the risk of multiples by limiting the number of embryos implanted in a single cycle.
For some women, an outpatient surgical procedure called “ovarian drilling” may be used to improve the ovaries response to medication. Your physician can help you assess when this option may be appropriate for you.
In summary, polycystic ovarian syndrome is a complex disorder with varied clinical presentations. Even the experts sometimes disagree on criteria for diagnosis, but there are numerous treatment options available that can be tailored to meet your particular circumstances. A specialized, complete evaluation will help you to understand your body and to choose effective treatment.
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