Polycystic Ovarian Syndrome (PCOS)

PCOS is the most common hormonal disorder of reproductive-age women and the most common problem we care for.  It affects approximately 5 percent of the population or one in twenty women.  Despite this, PCOS remains largely unknown, even by the women who have the syndrome.  PCOS is characterized by irregular menstrual periods, unwanted hair growth, being overweight (in more than half of the cases), difficulty in becoming pregnant, oily skin and/or acne.

Doctors Williams, Goodman and Smith are the regional specialists in the care of patients with PCOS.  They also have a research interest with PCOS.  Dr. Williams has been involved with PCOS research on Clomid and Metformin, the role of acupuncture in PCOS and sexual dysfunction related to PCOS.

The name “polycystic ovaries” is somewhat of a misnomer and a nonspecific term.  Women with PCOS have enlarged ovaries with tiny asymptomatic cysts seen on ultrasound.  It is true that 25 percent of normal women have ovaries that appear polycystic in ultrasound appearance, so the diagnosis cannot be made by ultrasound appearance alone.

Review Our Video Discussing PCOS

PCOS runs in families

It does appear that a predisposition for PCOS can be inherited but the genetic patterns remain unclear.  A daughter is estimated to have as high as a 50 percent risk of developing PCOS if her mother was affected.  The exact cause of PCOS has eluded investigators for decades but research indicates that excess insulin production is likely to be a key factor in many women.  The majority of overweight women with PCOS seem to have a cellular signaling mechanism for the hormone insulin that does not work efficiently, so that higher levels of insulin are required to achieve a normal response.

The excess insulin in PCOS also stimulates the ovaries to produce an overabundance of male-type hormones (for example, testosterone), referred to as androgens.  All women produce androgens but women with PCOS make too much.  The excessive androgens and other hormonal irregularities of PCOS lead to the lack of ovulation (resulting in irregular or absent menstrual periods), excessive unwanted hair growth, acne, oily skin, and increased risk of cardiovascular disease, elevated cholesterol, adult-onset diabetes and diabetes during pregnancy, and cancer of the uterine lining (endometrial cancer).  Women with PCOS have diminished fertility mainly because their ovulation is rare and unpredictable.

You have probably heard of the hormone insulin in connection with another disease:  diabetes.  In fact, the abnormal insulin-signaling mechanism involved in PCOS appears to be similar to the underlying cause of adult-onset diabetes.  Many scientists think that PCOS belongs on a spectrum of insulin problems, with PCOS on the mild end and Type 2 diabetes on the severe end.  Studies have shown that a large proportion of women with PCOS have other family members with Type 2 diabetes mellitus.  Women with PCOS need to realize they are predisposed to becoming a diabetic as they age.

Because PCOS affects one in twenty women, it is a very common cause of decreased fertility.  In fact, PCOS is the most common hormonal cause of infertility.  Women with PCOS often visit their doctors to report irregular bleeding.  If a woman with PCOS goes a few months without a menstrual period, her endometrium may build up to point where irregular bleeding occurs from overgrowth and breakdown of the tissue.  This bleeding can be heavy and require hormonal medications or, in severe cases, hospitalization with blood transfusions, and/or a surgical procedure called dilation and curettage (D&C).  Women with PCOS who have not had a menstrual period for a prolonged period of time will be at greater risk of developing cellular changes in the uterine lining called hyperplasia, which can progress to endometrial cancer if left untreated.  When ovulation does occur, the subsequent menstrual flow is often very heavy due to the thickened lining.

Blood testing is required to make the diagnosis

If your doctor has told you it is obvious from symptoms and a physical exam that you have PCOS, make sure you still have blood work completed.  If you or your doctor suspect you have PCOS, you should be fully evaluated.  Blood tests are necessary to help establish the diagnosis and rule out other diagnoses, such as diabetes.  A pelvic ultrasound is also necessary to establish the diagnosis.

PCOS Treatments

Clomid (clomiphene), letrozole and metformin are common oral medications used to assist patients to conceive by inducing ovulation.  Injectable FSH medications called gonadotropins are also commonly used by certified fertility specialists when the pills don’t work.  Metformin alone has been shown to be a poor choice when patients wish to get pregnant, as compared to clomiphene and letrozole.

For most overweight women with PCOS, the most effective treatment and the only true cure is losing weight.  A likely theory is that excess weight triggers PCOS by raising insulin levels to a threshold where they stimulate the ovaries to make more male-type hormones, enough to interfere with the normal menstrual cycle. The excess insulin is a powerful hormone, and it encourages the body to preserve its fat stores.  This leads to a vicious cycle of insulin-promoting weight gain and excess fat increasing insulin levels.

If you have PCOS and have found it extremely difficult to lose weight, you are not alone.  If a woman is obese, losing as little as 5 to 10 percent of her body weight has been shown to be enough to allow resumption of normal ovulation and menstrual cycles in many women with PCOS.  Because diabetes and PCOS are similar in their underlying mechanisms of disease, many reproductive endocrinology clinics are encouraging women with PCOS to try a modified diabetic diet or low carbohydrate diet to promote a natural reduction in insulin levels.  This means decreasing your intake of simple sugars and carbohydrates, while consuming more protein and non-starchy vegetables.

If you believe you have PCOS and you are overweight, you should plan an effective weight loss and exercise program.  Being overweight alone or in combination with PCOS is correlated with reproductive problems, including infertility, miscarriage, and pregnancy complications.

If you are in the minority of women with PCOS who are not above the normal weight ranges for your height, unfortunately weight loss is not the treatment for you.

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