Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS), formerly known as the Stein-Leventhal syndrome, is a condition where at least two of the following occur, and often all three:
• At least 12 tiny cysts (follicles) develop in ovaries.
• The balance of hormones that are made in the ovaries is altered. In particular, the ovaries make more than normal of the male hormone testosterone.
• Ovulation does not take occur each month. Some women do not ovulate at all. If no ovulation takes place then one may not have a period.
Besides period problems it causes reduced fertility, excess hair growth, and acne. Many women with PCOS are also overweight.
Understanding ovaries and ovulation
The ovaries are a pair of glands that lie on either side of the womb (uterus). The ovaries make eggs (ova) and various hormones. Ovulation normally occurs once a month when an egg (ovum) is released into a Fallopian tube which leads into the uterus. Before an ovum is released at ovulation, it develops within a little swelling of the ovary called a follicle (like a tiny cyst). Each month several follicles start to develop, but normally just one fully develops and goes on to ovulate.
• The main hormones that are made in the ovaries are oestrogen and progesterone – the main female hormones. These hormones help with the development of breasts, and are the main controllers of the menstrual cycle. The ovaries also normally make small amounts of male hormones (androgens) such as testosterone.

How common is polycystic ovary syndrome?
PCOS is common. It is difficult to know exactly how common, as figures vary depending on the definitions used and the countries studied. It is thought that around 1 in 10 women have PCOS – that is, at least two of: polycystic ovaries, a raised level of male hormone, reduced ovulation. However, these figures may be higher.
What causes polycystic ovary syndrome?
The exact cause is not totally clear. Several factors probably play a part. These include the following:
Insulin resistance
Women with PCOS have what is called insulin resistance. This means that cells in the body are resistant to the effect of a normal level of insulin. More insulin is then produced to keep the blood sugar normal. This raised level of insulin in the bloodstream is thought to be the main underlying reason why PCOS develops. It causes the ovaries to make too much testosterone. A high level of insulin and testosterone interfere with the normal development of follicles in the ovaries. As a result, many follicles tend to develop but often do not develop fully. This causes problems with ovulation – hence, period problems and reduced fertility.
It is this increased testosterone level in the blood that causes excess hair growth on the body and thinning of the scalp hair.
Increased insulin also contributes towards weight gain.
Luteinising hormone (LH)
This hormone is made in the pituitary gland (in the base of the brain.) A high level of LH is found in about 4 in 10 women with PCOS. A high LH level combined with a high insulin level means that the ovaries are likely to produce too much testosterone.
Family history
PCOS is not strictly inherited from parents to children, but it may run in some families.
Weight
Being overweight or obese is not the underlying cause of PCOS. However, being overweight or obese, can make insulin resistance worse. This may then cause the level of insulin to rise even further. High levels of insulin can contribute to further weight gain producing a ‘vicious cycle’. Losing weight, although difficult, can help break this cycle.
Symptoms of PCOS
Symptoms that occur if ovulation does not occur
Period problems occur in about 7 in 10 women with PCOS. They may have irregular or light periods, or no periods at all.
Fertility problems – A woman needs to ovulate to become pregnant. A woman with PCOS may not ovulate each month, and some women with PCOS do not ovulate at all. PCOS is one of the most common causes of not being able to get pregnant (infertility).
Symptoms that can occur if too much male hormone testosterone is made
Excess hair growth (hirsutism) occurs in more than half of women with PCOS. It is mainly on the face, lower tummy (abdomen), and chest. This is the only symptom in some cases.
Acne may persist beyond the normal teenage years.
Thinning of scalp hair (similar to male pattern baldness) occurs in some cases.
Other symptoms
Weight gain – about 4 in 10 women with PCOS become overweight or obese.
Depression or poor self-esteem may develop as a result of the other symptoms.
Symptoms typically begin in the late teens or early 20s. Not all symptoms occur in all women with PCOS. For example, some women with PCOS have some excess hair growth, but have normal periods and fertility. Symptoms can vary from mild to severe. Symptoms may also change over the years. For example, acne may become less of a problem in middle age, but hair growth may become more noticeable.
Possible long-term problems of polycystic ovary syndrome
A woman with PCOS, has an increased risk of developing type 2 diabetes, diabetes in pregnancy, a high cholesterol level, and possibly high blood pressure. These problems in turn may also increase the risk of having a stroke and heart disease in later life. Other possible problems in pregnancy include more chance of having babies too early or having pre-eclampsia (high blood pressure in pregnancy).
Diagnosis
Tests may be advised to clarify the diagnosis, and to rule out other hormone conditions.
• Blood tests may be taken to measure the male hormone testosterone and luteinising hormone (LH) which tend to be high in women with PCOS.
• An ultrasound scan of the ovaries may be advised. The scan can detect the typical appearance of PCOS with the many small cysts (follicles) in slightly enlarged ovaries.
Also, an annual screening test for diabetes or impaired glucose tolerance (prediabetes) may be advised. A regular check for other cardiovascular risk factors such as blood pressure, and blood cholesterol, may be advised to detect any abnormalities as early as possible. Exactly when and how often the checks are done depends on age, weight, and other factors. After the age of 40, these tests are usually recommended every three years.
Treatment for polycystic ovary syndrome
There is no cure for PCOS. However, symptoms can be treated, and health risks can be reduced.
Losing weight if overweight
Losing weight helps to reduce the high insulin level that occurs in PCOS. This has a knock-on effect of reducing the male chemical (hormone) called testosterone. This then improves the chance of ovulating, which improves any period problems, fertility, and may also help to reduce hair growth and acne. The increased risk of long-term problems such as diabetes, high blood pressure, etc, are also reduced.
Treating period problems
Some women who have no periods, or have infrequent periods, do not want any treatment for this. However, the risk of developing cancer of the womb (uterus) may be increased if one has no periods for a long time. Regular periods will prevent this possible increased risk to the uterus. Therefore, some women with PCOS are advised to take the contraceptive pill, as it causes regular withdrawal bleeds similar to periods. If this is not suitable, another option is to take progestogen hormone for several days every month, which will cause a monthly bleed like a period. Sometimes, an intrauterine system (IUS), which releases small amounts of progesterone into the womb preventing a build-up of the lining, can be used. If none of these methods is suitable, regular ultrasound scans of the uterus may be advised to detect any problems early.
Fertility issues
The chance of becoming pregnant depends on how often one ovulate. Some women with PCOS ovulate now and then, others not at all. If a woman does not ovulate but wants to become pregnant, then fertility treatments may be recommended by a specialist and have a good chance of success. If obese or overweight then losing weight is advised in addition to other fertility treatments.
Metformin and other insulin-sensitising medicines
Metformin is a medicine that is commonly used to treat people with type 2 diabetes. It makes the body’s cells more sensitive to insulin. This may result in a decrease in the blood level of insulin which may help to counteract the underlying cause of PCOS – see above. For certain people with PCOS, a specialist may advise that metformin be taken.
Preventing long-term problems
A healthy lifestyle is important to help prevent the conditions listed above.

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