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DESCRIPTION
Polycystic Ovary (Ovarian) Syndrome (PCOS) usually involves ovary enlargement from many small, fluid filled cysts in their ovaries. The hormonal regulation of the ovary malfunctions resulting in a reduction or absence of ovulation (the monthly release of the egg from the ovary), irregular or absence of a menstrual cycle and high levels of male hormones, also called androgens. PCOS can affect a woman's menstrual cycle, fertility, hormones, insulin production, heart blood vessels, and appearance. Women with this problem are often infertile. PCOS is the most common hormonal reproductive problems in women of childbearing age. It is estimated that 5 to 10 percent of women of childbearing age have PCOS.
FREQUENT SIGNS & SYMPTOMS
According to the American Society for Reproductive Medicine, PCOS is defined by the presence of any two of the following characteristics:
- Lack of ovulation for an extended period of time.
- High levels of androgens (male hormones).
- Many small cysts (fluid-filled sacs) on the ovaries.
Enlarged and/or polycystic ovaries. A woman may or may not have ovarian cysts with PCOS.
Irregular menstrual bleeding resulting in periods of light flow along with heavy flow. Absence of a menstrual cycle.
Infrequent menstrual periods. Increased time between periods, often up to several months.
Hirsutism which is the increased (excessive) hair growth on the face, arms, legs and from pubic area to navel from an increased level of androgens.
Male pattern baldness or thinning hair. Alopecia)
Higher energy level.
Obesity (weight gain), especially around the waist (central obesity) and abdomen.
Infertility - the inability to produce children.
Acne or oily skin.
Skin tags - small pieces of skin on the neck or armpits.
Acanthosis nigricans - darkened skin areas on the back of the neck, in the armpits, and under the breasts.
OVULATION & PCOS
Ovulation is a process in which a mature egg cell (also called an ovum), ready for fertilization by a sperm cell, is released from one of the ovaries (two female reproductive organs located in the pelvis). If the egg does not become fertilized as it travels down the fallopian tube on its way to the uterus, the endometrium (lining of the uterus) is shed and passes through the vagina (the passageway through which fluid passes out of the body during menstrual periods; also called the birth canal), in a process called menstruation.
With an ovulatory problem, the woman's reproductive system does not produce the proper amounts of hormones necessary to develop, mature, and release a healthy egg.
When the ovaries do not produce the hormones needed for ovulation and proper function of the menstrual cycle, the ovaries become enlarged and develop many small cysts which produce androgens.
Increased levels of androgens can also interfere with ovulation and normal menstrual cycles. About 20 percent of women with polycystic ovaries have normal menstrual cycles.
CAUSES
No one knows the exact cause of PCOS. PCOS results from a combination of several related factors.
Women with PCOS frequently have a mother or sister with PCOS. But there is not enough evidence yet to say there is a genetic link to this disorder.
An imbalance between the pituitary gonadotropin luteinizing hormone (LH) and follicle-stimulating hormone (FSH), resulting in a lack of ovulation and an increased testosterone production, a male sex hormone. Male hormones are called androgens.
Many women with PCOS have a weight problem. So researchers are looking at a relationship between PCOS and the body's ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches and other food into energy for the body's use or for storage. Many women with PCOS have insulin resistance, in which the body cannot use insulin efficiently. Since some women with PCOS make too much insulin, this leads to high circulating blood levels of insulin, called hyperinsulinemia. It is believed that hyperinsulinemia is related to increased androgen levels and it is possible that the ovaries react by making too many male hormones, androgens. This can lead to acne, excessive hair growth, weight gain (obesity), and ovulation problems as well as type 2 diabetes. In turn, obesity can increase insulin levels, causing worsening of PCOS.
RISK FACTORS
Risk increases with:
- Endometrial hypoplasia or carcinoma.
- Obesity.
- High blood pressure.
- Diabetes mellitus.
- Breast cancer.
Women with PCOS may be at increased risk for developing certain health problems. These may include:
- Metabolic syndrome - a condition with several components, including:
- Type 2 diabetes or insulin resistance.
- Elevated cholesterol levels.
- High blood pressure.
- Excess body weight, especially around the waist and abdomen.
- Elevated levels of C-reactive protein (a marker of inflammation).
- Elevated blood clotting factors.
- Heavy or irregular bleeding and endometrial cancer. Lack of ovulation for an extended period of time may cause excessive thickening of the endometrium (the lining of the uterus).
The symptoms of PCOS may resemble other conditions or medical problems. Always consult your health care provider for a diagnosis.
PREVENTIVE MEASURES
Cannot be prevented at present. Women should receive appropriate cancer screening tests to reduce the risk factors of uterine cancer and breast cancer.
EXPECTED OUTCOME
Hormone therapy can be used to decrease masculine characteristics and other hormonal therapy can be used to restore fertility. Some signs and symptoms may never disappear completely.
POSSIBLE COMPLICATIONS
Permanent hormone imbalance.
Infertility.
Increased likelihood of uterine cancer and breast cancer. See Risk Factors.
TREATMENT
GENERAL MEASURES
DIAGNOSIS & ASSESSMENT OF THE PCOS PATIENT
OBTAINING A PATIENT HISTORY. In addition to obtaining a thorough medical and surgical history, the health care provider elicits a completed menstrual history, including menarche and family history of PCOS. A history of hirsutism, acne, alopecia, menstrual irregularities, or infertility, especially in the patient's mother, is very important. A diagnosis of PCOS may often be made with a complete history. The practitioner should pay particular attention to the onset of menstrual irregularities, as this will usually date back to menarche. He/she should inquire about recent pregnancy status and other reproductive history such as miscarriages.
- MEDICAL HISTORY. A history of headaches or blurred vision (indicating pituitary tumor), any signs or symptoms of thyroid dysfunction (as a differential diagnosis of amenorrhea), or clinical signs of diabetes (indicating adrenal tumor) need to be elicited. Inquiry about a history of acne, hirsutism, deepening of the voice, and increase in muscle mass (without exercise). If these symptoms have occurred, what has been tried to control them? It is imperative to know if the symptoms are recent or have occurred rapidly, either of which could indicate a virilizing syndrome or neoplasia. A rapid onset of these symptoms is rare in a PCOS patient, but if present, they suggest a need for an urgent work-up, as an ovarian tumor or adrenal tumor needs to be ruled out. Also, masculinization is uncommon with PCOS patients and is more suggestive of congenital adrenal hyperplasia.
- FAMILY HISTORY. PCOS tends to run in families; it is important to ask about family history. Some believe that if a mother has PCOS and her daughter is showing signs of it, she should be evaluated by her pediatrician or by an endocrinologist.
- SOCIAL/CULTURAL HISTORY. Ethnic factors must be considered in the evaluation of women who are hirsute. Northern European white women and women from Asia usually have small amounts of hair on their face, torso, and extremities. However, Mediterranean white women will frequently have hair on their upper lip, chin, and have dark hair on their arms and legs. Also, certain conditions like pregnancy and menopause can cause transient hirsutism. An important caveat to remember is the patient may not appear hirsute at the time of the examination as she may be using cosmetic procedures like waxing, shaving, or electrolysis to control it.
- MEDICATIONS. In addition to asking about the patient's current medications it is important to remember that there are certain medications and classes of medications that can cause transient hirsutism. Examples of these are phenytoin (Dilantin), diazoxide, glucocorticoids, and the phenothiazines.
In addition to a complete medical history and physical examination, diagnostic procedures for PCOS may include:
- PHYSICAL & PELVIC EXAMINATION. A physical exam of both the internal and external female reproductive system.
Clinical Features: Evaluate the skin for evidence of hirsutism, acne, alopecia, fat distribution, and pigment changes in the skin, specifically acanthosis nigricans. Hirsutism can be defined as hair in locations in women where it is usually not found. Examples of these locations are upper lip, chin, midline of the body, and in the intermammary region. Hirsutism can be graded using the Ferriman-Gallowey scoring system (hirsutism chart). This scoring system evaluates 9 key anatomic sites. These sites can be graded from 0 (no terminal hair growth) to 4 (maximal growth). The maximum score is 36. A score of 8 or greater suggests an androgen excess.
REGIONS
1. Upper Lip
2. Chin
3. Chest
4. Upper Back
5. Lower Back
6. Upper Abdomen
7. Lower Abdomen
8. Arm
9. Forearm
10. Thigh
11. Leg
SITE GRADE DEFINITION 1. Upper Lip 1
2
3
4Few hairs at outer margin.
Small mustache at outer margin.
Mustache extending halfway from outer margin.
Mustache extending to midline.2. Chin 1
2
3 & 4Few scattered hairs.
Scattered hairs with small concentrations.
Complete cover, light and heavy.3. Chest 1
2
3
4Circumareolar hairs.
With midline hair in addition.
Fusion of these areas with 3/4 cover.
Complete cover.4. Upper Back 1
2
3 & 4Few scattered hairs.
More, still scattered.
Complete cover, light & heavy.5. Lower Back 1
2
3
4Sacral tuft of hair.
With some lateral extension.
3/4 cover.
Complete cover.6. Upper Abdomen 1
2
3 & 4Few midline hairs.
More, still midline.
Half and full cover.7. Lower Abdomen 1
2
3
4Few midline hairs.
Midline streak of hair.
Midline band of hair.
Inverted V-shaped growth.8. Arm 1
2
3 & 4Sparse growth affecting not more than 1/4 of limb quarter.
More, cover still incomplete.
Complete cover, light & heavy.9. Forearm 1, 2, 3 &4 Complete cover of dorsal surface;
2 grades of light and 2 grades of heavy growth.10. Thigh 1, 2, 3 &4 As for arm. 11. Leg 1, 2, 3 &4 As for arm.
Ferriman-Gallowey scoring system for hirsutism.
Even when a PCOS patient has increased levels of androgens, hirsutism may not be present unless there is an increase in peripheral androgen metabolism. This is why some women with PCOS are hirsute and others are not. Temporal balding is usually seen after prolonged exposure to androgens. Frontal balding is associated with a virilizing ovarian or adrenal tumor.
Central obesity with a hip ratio of >0.85 is associated with cardiovascular disease and is a marker for PCOS. A "buffalo hump" on the back or purple striae on the abdomen might suggest Cushing's syndrome.
During the pelvic examination, assess for clitoromegaly and pelvic masses. Bilateral pelvic masses would be more consistent with PCOS whereas a unilateral pelvic mass may be more consistent with a neoplasia. Remember, too, that the pelvic exam may not reveal any masses in a patient with PCOS.
- Laboratory studies of blood to check for increased levels of androgens and other hormone levels. Other blood tests used to identify problems related to PCOS may include glucose screening test for blood sugar levels and cholesterol and triglyceride blood levels.
Laboratory Studies: The results of the history, in concert with the physical examination, will guide the laboratory work up (Table 1).
Table 1. Laboratory Studies
LH (luteinizing hormone) FSH (follicle-stimulating hormone) TSH (thyroid-stimulating hormone) Prolactin Lipid panel: Cholesterol
HDL (High-density lipoprotein)
LDL (Low-density lipoprotein)
TriglyceridesFasting insulin level 2-hour 75-g glucose tolerance test DHEAS (Dehydroepiandrosterone sulfate) Testosterone Free testosterone 17-Hydroxyprogesterone
Table 2. Differential Diagnoses in Polycystic Ovaries
Pregnancy Premature ovarian failure Hyperthyroidism Hypothyroidism Pituitary adenoma Late-onset congenital adrenal hyperplasia Congenital adrenal hyperplasia Androgen-producing tumor of the ovary or adrenal gland Discontinuation of oral contraceptives Rapid weight loss Extreme physical exertion
This testing is designed to exclude life-threatening tumors and promote long-term health. Endocrine screening. Prolactin and thyroid-stimulating hormone (TSH) levels are tested to rule out pituitary or thyroid disease as an etiology of anovulation. LH and follicle-stimulating hormone (FSH) may be analyzed, and they are usually seen in a ratio of > 2.5 to 3. However, a normal LH/FSH ratio does not exclude the diagnosis of PCOS. An FSH level will also help rule out premature ovarian failure in a woman with amenorrhea.
Total testosterone and dehydroepiandrosterone sulfate (DHEAS) are evaluated to rule out an androgen-producing neoplasm. Total testosterone levels of 200 ng/dL are not generally seen in PCOS and suggest a virilizing tumor. DHEAS is a weak androgen that primarily comes from the adrenal glands. A level greater than 800 mcg/dL suggests a virilizing adrenal tumor.
17-hydroxyprogesterone (17OH-progesterone) is a useful screen for late-onset congenital adrenal hyperplasia (LOCAD). 17OH-progesterone levels less than 2 ng/mL are normal. A level > 5 ng/mL is diagnostic for LOCAD. A value between 2 ng/mL and 5 ng/mL should prompt an investigation with an adrenocorticotropic hormone stimulation test. If there is a suspicion for Cushing's syndrome, you may get a 24-hour urine for free cortisol or do a 1-mg dexamethasone suppression test overnight.
Endometrial Aspiration. Many PCOS patients have unopposed estrogen stimulation for prolonged periods of time and are thus at risk for endometrial hyperplasia or endometrial carcinoma. Any PCOS patient with prolonged oligomenorrhea or amenorrhea or a patient with PCOS who is older than aged 35 years and has irregular bleeding should have endometrial aspiration to rule out endometrial carcinoma. An important point to remember is that advancing age is not a factor in deciding to obtain endometrial aspiration in patients with PCOS as it is in non-PCOS patients.
Cardiac risk profile. Because PCOS patients have hyperandrogenism, they are at an increased risk of cardiovascular disease. It is imperative, then, that the patients are screened for an abnormal HDL, cholesterol, and triglycerides at 35 years of age. Normal results should be repeated in 3-5 years. If these results are abnormal, these entities can be treated early, thus reducing the risk of cardiovascular disease.
Glucose testing. Glucose tolerance testing is important. As many as 35% to 45% of PCOS patients will have impaired glucose testing and about 7% to 10% will have type 2 diabetes mellitus. A fasting glucose to fasting insulin ratio less than 4.5 is predictive of insulin resistance. Values on the 2HR glucose tolerance test are as follows: 2H > 140 mg/dL (normal); 140-199 mg/dl (impaired glucose); and < 200 mg/dL (type 2 diabetes).
- Ultrasound (Sonography). A diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. Ultrasound can determine if a woman's ovaries are enlarged or if cysts are present and evaluate the thickness of the endometrium. A vaginal ultrasound, in which an ultrasound transducer is inserted into the vagina, is sometimes used to view the endometrium. A pelvic ultrasound or endometrial biopsy to rule out hyperplasia or cancer.
Radiologic Studies. An enlarged uterus or enlarged ovaries palpated on pelvic examination suggests a need for a pelvic ultrasound to distinguish uterine fibroids from an adnexal mass. If a patient has elevated DHEAS, adrenal imaging is indicated. An important caveat to remember is that polycystic ovaries can been seen in a number of healthy women who do not have PCOS, and women with PCOS do not always have radiographically demonstrated polycystic ovaries. Remember, by ultrasound, 25% of "normal" ovulating women would have polycystic-appearing ovaries.
A transvaginal ultrasound should be done, as 90% of virilizing tumors can be identified with this method. Polycystic ovaries are also better evaluated transvaginally than transabdominally. Ovaries will have a typical appearance of enlarged subcapsular small follicles (> 10 mm) -- follicles are normally 2 mm to 10 mm in diameter. The ovarian volume in women with PCOS is > 10 cm3 and the normal range is 4.7-5.2 cm3.
No ideal medical treatment exists, drugs prescribed for the disorder will be determined by severity of symptoms and whether or not there is a desire for pregnancy.
You may need professional help if you want to remove excess hair from your face, arms and legs. Drugs may be prescribed, or other methods can include bleaching, electrolysis, plucking, waxing, or depilation.
TREATMENT
Specific treatment for PCOS will be determined by your health care provider based on:
- Your age, overall health, and medical history.
- Extent of the disorder.
- Cause of the disorder.
- Your signs and symptoms.
- Your tolerance for specific medications, procedures, or therapies.
- Expectations for the course of the disorder.
- Your opinion or preference.
Treatment for PCOS also depends on whether or not a woman wants to become pregnant. For women who do not want to become pregnant, treatment is focused on correcting the abnormal hormone levels, weight reduction, and managing cosmetic concerns. Treatment may include:
- Oral contraceptives (birth control pills) to regulate menstrual cycles, decrease androgen levels, and control acne.
- Diabetes medications - metformin, a medication used in the treatment of type 2 diabetes, is often used to decrease insulin resistance in PCOS. It may also help reduce androgen levels, slow hair growth, and help a woman ovulate more regularly. The safety of this medication in pregnancy has not been established.
- Weight reduction - a healthy diet and increased physical activity allow more efficient use of insulin and decrease blood glucose levels.
- medications to treat hair growth or acne.
For women who want to become pregnant, treatment is focused on weight reduction and promoting ovulation. Treatment may include:
- Weight reduction - a healthy diet and increased physical activity allow more efficient use of insulin, decrease blood glucose levels, and may help a woman ovulate more regularly.
- Ovulation induction medications - these medications stimulate the ovary to make one or more follicles (sacs that contain eggs) and release the egg for fertilization. For women with PCOS, these medications also increase the risks of having a multiple birth (twins or more) and ovarian hyperstimulation, a condition of excessive stimulation of the ovaries with hormone changes, abdominal bloating, and pelvic pain.
Women sometimes struggle with the physical changes that occur with PCOS, such as weight gain, hair growth, and acne. In addition to diet and medications, cosmetic procedures such as electrolysis and laser hair removal can often help a woman feel better about her appearance.
Because of the possible long-term health risks of PCOS, including heart disease and type 2 diabetes, women with PCOS should consult their health care provider about appropriate treatment.
MEDICATION
Progestin or oral contraceptives for women not desiring pregnancy.
A few drugs have been tried for the excess hair (hirsutism), but the success rate is not high, and side effects are numerous.
ACTIVITY
No restrictions on activity, including sexual intercourse.
DIET
No special diet specific for PCOS. However, you will need to work with a dietician to help you with your nutrition. Weight loss may be recommended if you are over-weight.
PCOSupport Living: Thoughts on PCOS & Nutrition / Lifestyle
Balance is important
The balance of food you eat can be an important part of treating PCOS. Foods rich in carbohydrates, such as bread, pasta, rice, potato, fruit and fruit juices, and sweet desserts, are quickly broken down into sugar when digested. This sugar is then absorbed into your blood triggering your pancreas to release insulin to carry that sugar into your cells. Once inside, the sugar can be used for energy. Many women with PCOS, however, are insulin resistant, meaning our cells are not responding as well as they should to insulin, so our pancreas sends out more and more insulin to do the job. This excess of insulin is a link in a chain of reactions contributing to the symptoms of PCOS.
Remember - carbohydrates are not bad! Carbohydrates are necessary for good nutrition, an important source of energy, fiber, and vitamins. Choosing carbohydrate-rich foods wisely and balancing your meals is the name of the game.
Examine your diet. Ask yourself the following questions as you change your diet.
- Will my hunger be satisfied?
- Will I get all necessary nutrients and calories?
- Can I make this way of eating a permanent part of my lifestyle?
- Just what is a balanced meal, anyway?
- What about special occasions when I want to splurge?
- Do I have other medical conditions to consider, such as high cholesterol or diabetes?
Depending on how you answered these questions, you can determine if you are on the right track in changing your diet for PCOS. A registered dietitian can help.
What is a registered dietitian (RD)? The letters "RD" after a name attests to completion of academic and practice requirements and means this person is qualified help you. Becoming a registered dietitian requires a minimum of a bachelor's degree followed by an accredited internship program. RDs must successfully pass a national credentialing exam and show proof of continuing education throughout their careers. This qualifies the registered dietitian as the nutrition expert; your best source for reliable nutrition information. Registered dietitians are skilled in translating science into practical dietary advice to guide your food choices. RDs may be referred to as "nutritionists," but a "nutritionist" is not necessarily a registered dietitian.
Dietary treatment for PCOS is a new topic for many dietitians. Choosing a dietitian with experience in type 2 diabetes and gestational diabetes is a good choice because he or she will be knowledgeable about insulin resistance. Speak with the dietitian before making the appointment and get an idea of what a counseling session involves. Specifically find out:
- Is the diet plan tailored to the individual?
- Is this dietitian open to lower carbohydrate diet planning?
- If your dietitian is not experienced with PCOS, you might suggest the August 2000 issue of the Journal of the American Dietetic Association and the January 2001 issue of Dietitian's Edge for professional articles about PCOS and nutrition. Finally, at the session, be sure to ask the following questions so you come home with a plan you can live with.
- How much carbohydrate is right for me? Less carbohydrate than recommended for the general population has been suggested for PCOS. 40 - 50% may be a good starting point. Upon deciding the level of carbohydrate, your dietitian can help you design a meal plan for overall balance, including the right amount of protein and fat.
- What are some of the most concentrated sources of sugar I am eating right now? Cutting back on these foods is a great place to start.
- What rate of weight loss can I expect? This may take some fine-tuning over several weeks or months. Your rate of weight loss depends upon a combination of factors, such as your calorie intake and the amount of exercise in your lifestyle.
- How can my favorite foods fit in? Choose a dietitian you feel comfortable with and who will take your goals into consideration. And remember - your dietitian wants you to succeed, so be sure all your questions are answered. Once you focus on your specific dietary needs, you'll have an effective tool to help manage your PCOS.
There is a wide range of supplemental nutrients that may help you alleviate the symptoms of polycystic ovarian syndrome (PCOS) and reduce the incidence of ovarian cysts. Not all of them are appropriate or necessary for every woman. We recommend that you consult with a licensed health care professional regarding the best supplements for you.
Listed below are some supplements that some health practitioners use for treating various aspects of polycystic ovary syndrome.
Supplemental Nutrient Fertility
& Sex
Hormone
BalanceInsulin
or
Glucose
ControlHair Acne Weight
or
Appetite
ControlAnti-
OxidantNeed
if
Taking
Drugs5-hydroxy-
tryptophan- - - - Yes - - Alpha lipoic acid - - - - - Yes - Bilberry - - - - - Yes - Biotin - - Yes - - - - Chromium - Yes - - - - - Cinnamon root - Yes - - - - - CLA - - - - Yes - - Fish Oil Yes Yes - - Yes - - Gymnema Indole 3 carbanol Yes - - - - - - Inositol - Yes - - Yes - - Licorice Magnesium - Yes - - Yes - - Momordica Multi-vitamin/mineral Yes Yes Yes Yes Yes Yes Yes NAC - - - - - Yes - Natural progesterone Yes - - - - - - Quercetin Saw Palmetto Yes - Yes Yes - - - Vanadyl sulfate Vitamin B-12 & Folic acid Yes Vitamin B-6 Vitex (chasteberry) Yes - - Yes - - - Zinc
"Chromium picolinate, which has positive effects on insulin sensitivity in people with type 2 diabetes, looks like it has great potential as a safe, effective long-term therapy to fill a void in treating PCOS," said Michael L. Lydic, MD, assistant professor at SUNY Reproductive Endocrinology Division, who led the study. "If larger, controlled trials confirm chromium picolinate's efficacy, PCOS patients could potentially take the supplement every day to decrease their risk of diabetes and possibly improve other physical and symptomatic effects of PCOS. It also has potential to be used in combination with prescription insulin-sensitizing drugs." Chromium is an essential mineral that is needed for insulin activity in carbohydrate, fat and protein metabolism. Numerous clinical trials have shown that chromium as chromium picolinate reduces insulin resistance, improves blood sugar control and may help reduce the risk of cardiovascular disease and type 2 diabetes.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or your family member has symptoms of polycystic ovarian syndrome.
Your periods become profuse or more frequent than usual.
You develop a lump or swelling in the breast.
Symptoms recur after treatment or surgery.
You want a referral to remove excess body hair.
New, unexplained symptoms develop. Drugs used in treatment may produce side effects.
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