Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) is an endocrine system disorder that occurs in 5-10% of women of reproductive age.

What is Polycystic Ovary Syndrome?

Polycystic Ovary Syndrome (PCOS) is a condition characterized by enlargement of the ovaries, ovarian cysts, and hormone imbalance. Hormones are chemical messengers that perform vital bodily functions and have a huge impact on your health.

In PCOS the sex based hormones are out of balance, resulting in issues with the menstrual cycle, fertility, ovarian cyst formation, acne, body hair, weight gain, mood, and overall well being.

While the ovaries release a small amount of androgens (male sex hormones) in all women, in women with PCOS, the ovaries release more than required. When there is elevated androgen secretion, the follicles in the ovaries will not develop and consequently there will be no ovulation. If a woman does not ovulate then she is incapable of becoming pregnant.  In addition, when no ovulation occurs it is accompanied by the development of cysts within the ovaries.

Further more, without ovulation progesterone is not released. Without progesterone, estrogen goes unopposed, leading to increased levels of estrogen and decreased levels of progesterone. Excess estrogen can result in longer and heavier periods, water retention, weight gain, acne, fatigue, thyroid dysfunction, and more.

Causes of polycystic ovary syndrome (PCOS)

While the cause of Polycystic Ovary Syndrome is not completely understood, it is believed to have a genetic and environmental component. The main culprit of PCOS however, is a dysfunction within the Hypothalamus-Pituitary-Ovarian Axis, which is the signaling system between the brain and body. The Hypothalamus-Pituitary-Ovarian Axis system is very important as it is needed for regulation of hormones and to maintain homeostasis.

Hypothalamus-Pituitary-Ovarian Axis Overview: in a healthy functioning body, the hormones produced in the hypothalamus will stimulate the secretion of the various hormones from the pituitary gland. All of this occurs in the brain. From there, the hormones secreted from the pituitary gland will travel to, and act on, their specific target organs. This system effects all parts of the body, but in PCOS we are dealing with the sex hormones and the ovaries.

Hormones of the Ovaries: Gonadotropin-Releasing Hormone (GnRH) is produced and secreted from the hypothalamus, which causes the release of Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH) from the pituitary gland. The hormones LH and FSH then stimulate the ovaries to produce estrogen and progesterone.

With PCOS, there is an increase in the release of GnRH from the hypothalamus, which results in increase in the LH:FSH ratio and an elevation in androgen release. Changes in LH:FSH ratio can lead to a disruption in ovulation.

Androgens in women are produced in the ovaries, adrenal glands, and fat cells. Androgen levels increase with high levels of LH, but also due to high levels of insulin that are usually seen with PCOS. This is why women who are overweight are at increased risk for PCOS.

Symptoms

In many instances, women present with symptoms shortly after they begin their menses. For others, symptoms appear later in a woman’s reproductive years, especially if the individual has gained a significant amount of weight. It is not unusual for women to go undiagnosed until they present to their OB/Gyn with concerns of infertility.

The classic symptoms associated with women who have undiagnosed PCOS include:

  • Infertility
  • Irregular periods: can miss periods or have heavier and prolonged menstruation
  • Increased hair growth all over the body, including the face
  • Hair loss or thinning of the hair
  • Acne
  • Obesity or weight gain
  • Darkening of the skin
  • Cysts on the Ovaries
  • Anxiety or depression

While most of these symptoms are classic indications of this disorder, each individual is still unique and may present differently.

Diagnosis

Polycystic Ovary Syndrome is a complex disorder and diagnosis is based on a combination of exclusion, symptoms, and tests. It has been decided that women must present with two of these three to be diagnosed:

  • Irregular menstrual periods
  • Evidence of elevated androgen levels
  • Polycystic ovaries

The Society of Obstetricians and Gynecologists state that the definition of polycystic ovaries is when the ovary has greater than 12 small antral follicles.

Laboratory testing will often include: testosterone, estrogen, prolactin, DHEA-S, sex hormone binding globulin (SHBG), androstenedione, FSH, LH. Due to the metabolic component of PCOS fasting glucose levels, insulin levels, TSH, free thyroxine, and lipids are often evaluated as well.

In PCOS results may be as follows:

  • Increased free testosterone
  • DHEA-S slightly increased
  • Low SHBG
  • Increased androstenedione
  • Normal to low FSH
  • Increased LH
  • LH:FSH ratio greater than 3.
  • Elevated estrogen

If PCOS is suspected then imaging studies may be required to evaluate the patient further. Ultrasound is the gold standard to evaluate if the ovaries are developing follicles. While abdominal ultrasound may provide limited results, the trans-vaginal ultrasound is preferred for better visualization of the ovaries.

CT or MRI imaging studies may be required if the physician believes the patient may have an adnexal or adrenal tumor. A biopsy of the ovaries may also be indicated for confirmation of a PCOS diagnosis. Histological evaluation of an ovarian biopsy will indicate: enlarged, sclerotic tissue with multiple cystic follicles.

Other disorders that must be ruled out include: adrenal tumors, ovarian tumors, thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and cushing syndrome. Each of these disorders listed above may result in the increased production of androgens. These can be ruled out using laboratory evaluation, imaging, and physical examination by the medical provider.

Treatment

Patient education, lifestyle changes, and hormone supplements/ oral contraceptives make up the cornerstone of treating PCOS.

Weight loss: it has been found that women who lost 5 to 10 percent of their body weight notice that their periods become more regular, have improved symptoms, and often regain ovulation.

Hormone Regulation: oral contraceptives that contain both estrogen and progesterone can help to regulate the menstrual cycle, alleviate abnormal bleeding, and decrease the production of androgens in the body. They can also reduce unwanted symptoms such as hair growth, weight gain, and acne. It may take a few months on the pill to get fully regulated and some will do better on low estrogen pills.

Progesterone can also be used to treat menstrual irregularity, but it does not help with the excess hair and acne. Progesterone comes in cream, pill, patch, or IUD form.

Excess Hair: if after 6 months on hormone treatments the hair growth is not reduced, medications such as spironolactone can be used. Spironolactone is a diuretic medication that actually blocks the effects of androgens on the skin and will result in a reduction of hair growth.

Pregnancy: Weight loss is the best method to achieve ovulation. However, there are also medications that can help simulate ovulation in women who are trying to conceive. Clomiphene for example, belongs to is a class of medications called ovulatory stimulants, works on the ovaries to release one or more eggs.

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