What is polycystic ovarian syndrome?

Polycystic ovarian syndrome (PCOS), also known as Stein-Leventhal syndrome or polycystic ovary disease, is a hormonal condition in which the ovaries are enlarged and contain many small, fluid-filled cysts. It occurs when your ovaries produce more of the male hormones (androgens) than the small amount considered normal.

Normally, during each menstrual cycle, many small follicles (sacs) grow in your ovaries and form eggs. At mid-cycle, or ovulation, an egg is released from one of the ovaries and all the other follicles 'over-ripen' and break down. However, in PCOS, ovulation does not occur and an egg is not released. The follicles do not break down, but fill with fluid and turn into cysts. The ovaries can then swell in size, sometimes becoming two to five times larger than normal.

Women with PCOS sometimes develop some more masculine characteristics such as excess facial or body hair, acne, hair loss in the same pattern as male baldness and fat deposits around the abdomen.

PCOS is a relatively common condition. Estimate are that it affects up to 10% of all premenopausal women. It is one of the leading causes of infertility, yet many women do not know they have it.

The cause of PCOS

The cause of PCOS is still uncertain. However, the condition is known to be associated with the body being resistant to the actions of insulin (the hormone that helps you regulate blood sugar levels). Because of this, PCOS might share some similarities with diabetes. New research suggests that the ovaries of women with PCOS produce more male hormones than normal because these women cannot process insulin properly. It is known that, if insulin levels in the blood are too high, the ovaries react by producing more male hormones.

Symptoms of PCOS

Symptoms of PCOS can begin at any age. They may develop during puberty and the start of menstrual periods may be delayed or not happen at all. Girls or women with PCOS may be overweight and have body hair growing in a male pattern, such as on the chest and face. Or they may have irregular and heavy vaginal bleeding.

Each woman’s symptoms may be different, but usually they will include some or all of the following:

• excessive hair growth on the face, chest or abdomen (hirsuitism)
• irregular or absent periods
• abnormal bleeding from the uterus 
• high blood pressure
• acne 
• obesity, particularly centred around the middle 
• thinning hair or hair loss in a classic ‘male baldness’ pattern 
• problems getting pregnant, or infertility
• symptoms of diabetes, such as thirst or excessive urination, vaginal thrush (candidiasis) or chronic skin infections 
• polycystic ovaries, shown on ultrasound scans.

About 20% of women (pre-menopause) are shown to have polycystic ovaries on ultrasound yet may have no symptoms of PCOS itself.

Diagnosing PCOS

There is no easy test for PCOS, so your doctor will need to assess your symptoms, your medical history and physical appearance.

If your doctor suspects you have PCOS, he or she will probably arrange tests to confirm it and rule out other more serious medical conditions. These tests may include: 

• an ultrasound scan to give a view of your ovaries
• blood tests to check your levels of male hormones, insulin, glucose, cholesterol or luteinising hormone (which stimulates ovulation).
  

Complications of PCOS

PCOS can increase your chances of developing health problems later in life, so it is important to have regular medical check-ups. Even though some PCOS symptoms may lessen after the menopause, this is likely to be the time many of the long-term associated conditions appear. These can include the following. 

• Type 2 diabetes. The difficulty most women with PCOS have in processing insulin tends to get worse with age. By the time of menopause, about 50% of women with PCOS are diagnosed with type 2 diabetes. Because of this, it is important to follow a healthy diet and maintain an exercise programme long before menopause. 
• Increased cholesterol levels. High levels of testosterone can cause the levels of LDL-cholesterol (so-called ‘bad’ cholesterol) in your blood to go up, resulting in an increased risk of heart disease and heart attack. 
• Endometrial cancer. Because women with PCOS do not ovulate often, they have infrequent periods, which results in a build-up of the lining of the uterus (endometrium). This may increase the risk of the uterine lining producing abnormal cells that can turn into cancer, although this is not known for certain.

Treatments for PCOS

Although PCOS cannot be cured, some of the symptoms can be controlled. Treatment depends on your symptoms and how severe they are, and your feelings regarding pregnancy.

Self-help approaches

Exercise and weight loss are very important. These measures alone help some women with PCOS become pregnant. Your doctor may suggest a special diet to try to normalise your insulin levels and keep your cholesterol levels at an acceptable level.

Medications

• You may be prescribed progestogen (a synthetic version of the female hormone progesterone) or the contraceptive pill to induce regular periods.
• Some low-dose contraceptive pills contain oestrogen and a small amount of the anti-androgen (a substance which blocks the effects of male hormones) cyproterone acetate. This is very effective in keeping excess hair growth under control and improving acne. 
• Cyproterone acetate is also available by itself and your doctor may suggest you try this or another anti-androgen, spironolactone, whch works in a similar way. Sometimes excessive hair growth is best managed with both medical treatment and electrolysis or laser therapy. Your doctor can advise what’s best for you. 
• Isotretinoin is used for severe acne that hasn’t been helped by other treatments. It works by reducing the amount of oil the skin produces and shrinking the oil glands in the skin. It is usually prescribed by a specialist doctor as it has numerous side effects. It should not be used in pregnancy or if you might become pregnant as there is a high risk of permanent damage to the unborn baby. 
• Drugs such as metformin, which helps your body make better use of the insulin it produces, may also be prescribed. These medicines help women with PCOS lose weight, reduce blood pressure and can often restore the menstrual cycle, as well as helping control excess body hair caused by high testosterone levels.

With all these medicines, it's important to remember they may take some time to work. Also, you will need to remove any existing hair growth manually using a method such as bleaching, waxing or electrolysis, as the medicines do not do this.

Fertility treatment can include the use of drugs such as clomiphene citrate, which stimulates the ovary to follicles so that an egg is released mid-cycle, or injections of synthetic hormones similar to the naturally produced hormones.

Surgery

As a treatment for infertility, your doctor may suggest surgery called laparoscopic ovarian drilling, which uses either a hot needle or laser to cauterise the ovary in several places. This procedure can stimulate ovulation and increase the chances of conceiving. However, surgery is generally considered a last option because scar tissue can form on the ovaries as a result, which may in fact further reduce your ability to get pregnant in the future.

Original material provided by myDr, reviewed by everybody June 2009.