PCOS is a very common endocrine disorder where there is an imbalance in the female sex hormones. These imbalances lead to problems with ovulation, excess androgens or masculinizing hormones and insulin resistance. As a result, someone with PCOS might struggle with irregular periods, difficulty becoming pregnant, acne, abnormal hair growth, obesity, elevated cholesterol, and type 2 diabetes. However, not every women with PCOS will exhibit all of these symptoms. Irregular periods or difficulty getting pregnant could be the only signs. PCOS also appears to be a genetic disease, as there is increased incidence in women with a mother or sister who have PCOS.
How is PCOS diagnosed?
According to the Rotterdam criteria, the diagnosis of PCOS is made if you exhibit at least 2 of the following criteria.
1) Irregular periods (>38 day cycle length) or lack of periods
2) Polycystic ovaries on ultrasound (enlarged ovaries with multiple small cysts, often times they are distributed along the edge of the ovary in a row giving a “string of Pearls” appearance)
3) Hyperandrogenemia (elevated levels of free or total testosterone) OR signs of hyperandrogenism, such as acne and hirsutism (dark coarse hairs in male pattern areas, such as chin, chest or abdomen).
We also need to rule out other etiologies for these signs and symptoms, such as high prolactin levels, abnormal thyroid function, androgen secreting tumors, and congenital adrenal hyperplasia, another endocrine disorder.
Additionally, once you have been diagnosed with PCOS, you are at increased risk for elevated cholesterol, diabetes, heart disease, sleep apnea, and endometrial cancer and need to be monitored more closely for these things.
How does PCOS relate to infertility?
Ovulation, which requires precise elevations of LH and FSH from the hypothalamus at precise times, gets disrupted in PCOS because there is an imbalance of these female sex hormones. Women with PCOS ovulate infrequently and sometimes not at all. As you remember from our initial blog about conception and infertility, one of the requirements for conception to occur is that ovulation must be occurring (releasing of an egg each month). Thus, women with PCOS may have a difficult time getting pregnant.
What is the treatment for PCOS?
There isn’t one treatment for PCOS; instead there are multiple treatments that help with the effects of PCOS.
1) Birth Control Pills:
If you aren’t trying to become pregnant, birth control pills can be used to treat irregular periods, making them regular. They also help improve acne and slow hair growth.
2) Exercise and Weight loss:
A decrease in body weight by even as little as 5%, can help decrease the effects of PCOS, including anovulation, insulin resistance, and hyperandrogenism.
This medication decreases both liver glucose production and intestinal glucose absorption. It is also an insulin sensitizer that makes glucose more sensitive to breakdown by insulin. Metformin may help slow the progression of pre-diabetes to overt diabetes. It also decreases LH and free testosterone levels, and increases SHBG. All of these things help restore the normal balance of female sex hormones, improving menstrual function, with more regular periods and ovulation. Metformin is not typically used alone as a first-line fertility medication as it was not shown to improve live birth rates compared to the medication Clomid (Legro, 2007).
This is an antiandrogen that can be helpful in preventing the excessive hair growth. This medication can be harmful to a growing fetus, so it is imperative that a woman on this medication isn’t pregnant.
5) Clomid or other medications that induce ovulation:
This can be used alone or in conjunction with Metformin to help induce ovulation in women with PCOS who are trying to become pregnant. (see our last blog for more information about Clomid).
6) Other treatments, such as laser hair removal, acne medications, and medications to treat high cholesterol levels or diabetes may be indicated.
Legro, et al. New England Journal of Medicine, 2007.