('''PCOS''', also known clinically as '''Stein-Leventhal syndrome'''), is an
Endocrine Disorder that affects 5–10% of women. It occurs amongst all races and nationalities, is the most common hormonal disorder among women of reproductive age, and is a leading cause of
Infertility . The symptoms and severity of the syndrome vary greatly between women. While the causes are unknown,
Insulin Resistance (often secondary to
Obesity ) is heavily correlated with PCOS.
Other names for this disorder include
- Polycystic ovary disease (although this is not correct because PCOS is characterized as a syndrome rather than a disease)
- Functional ovarian hyperandrogenism
- Hyperandrogenic chronic anovulation
- Ovarian dysmetabolic syndrome
Two definitions are commonly used:
#In 1990 a consensus workshop sponsored by the
NIH /
NICHD suggested that a patient has PCOS if she has (1) signs of
Androgen excess (clinical or biochemical), (2)
Oligoovulation , and (3) other entities are excluded that would cause polycystic ovaries.
#In 2003 a consensus workshop sponsored by and/or
Anovulation , (2) excess androgen activity, (3) polycystic ovaries (by
Gynecologic Ultrasonography ), and other causes of PCOS are excluded.
The Rotterdam definition is wider, including many more patients, notably patients without androgen excess, whereas in the NIH/NICHD definition androgen excess is a prerequisite. Critics maintain that findings obtained from the study of patients with androgen excess cannot necessarily be extrapolated to patients without androgen excess.
Common symptoms of PCOS include
- Oligomenorrhea , Amenorrhea - irregular, few, or absent Menstrual Period s; cycles that do occur may comprise heavy bleeding (check with a gynecologist because heavy bleeding is also an early warning sign of Endometrial Cancer , for which women with PCOS are at higher risk)
- Infertility , generally resulting from chronic Anovulation (lack of ovulation)
- Elevated serum (blood) levels of Androgen s (male hormones), specifically testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS), causing Hirsutism and occasionally Masculinization
- Central Obesity - "apple-shaped" Obesity centered around the lower half of the torso
- Androgenic Alopecia (male-pattern baldness)
- Acne , oily skin, Seborrhea
- Acanthosis Nigricans (dark patches of skin, tan to dark brown or black)
- Acrochordon s (skin tags) - tiny flaps of skin
- Prolonged periods of PMS -like symptoms ( Bloating , Mood Swing s, Pelvic Pain , Backaches )
- Sleep Apnea
Signs are:
- Multiple cysts on the ovaries. Sonographically they may look like a string of pearls.
- Enlarged ovaries, generally 1.5 to 3 times larger than normal, resulting from multiple cysts
- Thickened, smooth, pearl-white outer surface of ovary
- Chronic pelvic pain, possibly due to pelvic crowding from enlarged ovaries; however, the actual cause is not yet known
- The ratio of LH ( Luteinizing Hormone ) to FSH ( Follicle Stimulating Hormone ) is greater than 1:1, as tested on Day 3 of the menstrual cycle.
- High levels of Testosterone .
- Low levels of Sex Hormone Binding Globulin .
- Hyperinsulinemia .
Women with PCOS are at risk for the following:
Some data suggest that women with PCOS have a higher risk of
Miscarriage . Also, many women with PCOS have a difficult time conceiving because of their irregular cycles and lack of ovulation. However, it is possible for these women to have normal pregnancies with the aid of medication and diet.
It is vital to note that not all women with PCOS have polycystic ovaries, nor do all women with ovarian cysts have PCOS; although a
Pelvic Ultrasound is a major diagnostic tool, it is not the only one. Diagnosis can be difficult, particularly because of the wide range of symptoms and the variability in presentation (which is why this disorder is characterized as a syndrome rather than a disease).
There is a lot of controversy about the appropriate testing:
The role of other tests is more controversial, including
- fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women who will need higher dosages of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance.
- LH:FSH ratio
- DHEAS
- SHBG
- Androstenedione
Other causes of irregular or absent menstruation and hirsutism, such as
Congenital Adrenal Hyperplasia ,
Cushing's Syndrome ,
Hyperprolactinemia , and other pituitary or adrenal disorders, should be investigated.
PCOS develops when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, either through the release of excessive luteinizing hormone (LH) by the pituitary gland or through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus.
This syndrome acquired its most widely used name because a common symptom is multiple (poly) ovarian
Cyst s. These form where egg follicles matured but were never released from the
Ovary because of abnormal hormone levels. These generally take on a 'string of pearls' appearance. The condition was first described in
1935 by Dr. Stein and Dr. Leventhal, hence its original name of Stein-Leventhal syndrome.
Although the cause of PCOS is not known, research to date suggests that
Obesity is a prime indicator. It may have a genetic predisposition, and further research into this possibility is taking place. No specific gene has been identified, and it is thought that many genes could contribute to the development of PCOS.
A majority of patients with PCOS - some investigators say all - have insulin resistance. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Specifically, hyperinsulinemia increases
GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding; all these steps lead to the development of PCOS. Insulin resistance is a common finding in obese people.
Medical treatment of PCOS used to be directed mainly at the symptoms (ovarian and adrenal suppression and
Anti-androgen therapy) and at restoring
Ovulation . Some medications used for these purposes are
Recent research suggests that the hydrochloride (Glucophage®),
Pioglitazone hydrochloride (Actos®), and
Rosiglitazone maleate (Avandia®) helpful, and ovulation may resume when they use these agents. Many women report that
Metformin use is associated with upset stomach, diarrhea, and weight-loss. Both symptoms and weight loss appear to be less with the extended release versions. Most published studies use either generic metformin or the regular, non-extended release version. Starting with a lower dosage and gradually increasing the dosage over 2-3 weeks and taking the medication toward the end of a meal may reduce side effects. The use of
Basal Body Temperature or BBT charts is an effective way to follow progress. It may take up to six months to see results, but when combined with exercise and a
Low-glycemic Diet up to 85% will improve menstrual cycle regularity and ovulation.
Low-carbohydrate Diet s and sustained regular exercise are also beneficial. Also, initial research suggests that the risk of miscarriage is significantly reduced when
Metformin is taken throughout pregnancy (9% as opposed to as much as 45%); however, further research is needed in this area.
For patients who do not respond to these and related medications or procedures, the polycystic ovaries can be treated with surgical procedures such as
- laparoscopy electrocauterization or laser cauterization
- ovarian wedge resection (rarely done now because it is more invasive and has a 30% risk of adhesions, sometimes very severe, which can impair fertility)
- ovarian drilling
- Ehrmann DA. ''Polycystic ovary syndrome.'' N Engl J Med 2005;352:1223-36. PMID 15788499.
Spirinolactone is a potassium sparing diuretic and does not block the affects of androgen as implied by the above text. Finasteride however is a 5-alpha reductase inhibitor and so does prevent androgen actions by preventing testosterone being converted to the more bioactive, dihydrotestosterone form.
