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Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. It can cause infertility and other symptoms. Patients with PCOS may have irregular or absent menstrual periods and hyperandrogenism (elevated serum testosterone and androstenedione). In women with PCOS, failure to ovulate is the most common reason for not conceiving.
This page discusses the following topics:
Description
Women with PCOS usually have a normal uterus and fallopian tubes,
but their ovaries contain many small follicles or cysts, visible on
ultrasound. Each contains an egg, but they don't grow normally and
shrink before ovulation. Each month, new follicles develop and
shrink into cysts. On occasion, but rarely, the patient may ovulate
and conceive, but most of the cysts remain too small. These cysts
don't indicate an increase in the risk of ovarian cancer and do not
need to be removed.
Most PCOS cases are unexplained. The disorder may be inherited, and
is believed to arise from a deficiency in luteinizing hormone (LH),
one of the hormones that controls follicle growth, or a resistance
to insulin. A similar effect on the ovaries can occur in women with
eating disorders (anorexia or bulimia), or women whose bodies do not
properly make estrogen and other steroids (for example, women with
congenital adrenal hyperplasia).
PCOS is the most common cause of menstrual irregularity in
premenopausal women. These women have long-term health risks
associated with PCOS. Treatment can improve the chances of
conceiving and reduce the risk of developing diabetes or heart
disease. Behavior modification is the cornerstone of treatment for
long-term effects and may delay the onset of disease.
Symptoms
Patients with PCOS may have:
- Menstrual irregularities, abnormal bleeding
- Impaired fertility
- Higher miscarriage rates
- Increased hair growth and acne
- Obesity (about half of women with PCOS are obese)
- Abnormal insulin action (40 percent of women with PCOS from insulin resistance will develop gestational diabetes, and 50 percent will develop diabetes)
- Heart disease
- Breast milk secretion
- Higher risk of developing endometrial (uterine) abnormalities, including uterine cancer.
Infertility treatment for women with PCOS
Before fertility treatment begins, your doctor should examine your fallopian tubes and uterus (with a hystersalpingogram or laparoscopy), and perform a semen analysis. The most common treatment that allows patients with polycystic ovary syndrome to ovulate and conceive is ovulation induction with clomiphene citrate or gonadotropins.
Ovulation induction - Medication may induce ovulation in women who do not ovulate regularly. The first medicine used is usually clomiphene citrate (brand names Clomid, Serophene). It is usually taken daily for five days early in the menstrual cycle. If clomiphene citrate fails to induce ovulation or pregnancy (within four cycles), your doctor may prescribe injectable hormones, known as gonadotropins.
Follistim and Gonal-F are injectable medications that contain follicle stimulating hormone (FSH). The patient injects the FSH daily, with medical monitoring of serum estradiol levels and pelvic ultrasound examinations. Monitoring is particularly important for women with PCOS because of their increased risk of ovarian hyperstimulation syndrome. When the follicles are mature, an injection of human chorionic gonadotropin (hCG) is timed to stimulate ovulation. Patients who use gonadotropins run a 16-18 percent risk of multiple pregnancies (twins, triplets, etc.).
Women with PCOS may be treated with in vitro fertilization (IVF). IVF-induced pregnancy rates for PCOS patients are generally excellent, but these patients have a higher risk of ovarian hyperstimulation syndrome.
PCOS and Insulin Resistance
One of the major biochemical features of polycystic ovary syndrome is insulin resistance accompanied by hyperinsulinemia (elevated fasting blood insulin levels). There is increasing data that hyperinsulinemia produces the hyperandrogenism of polycystic ovary syndrome by increasing ovarian androgen production, particularly testosterone and androstenedione and by decreasing the serum sex hormone binding globulin concentration. The high levels of androgenic hormones lead to increased LH levels, poor follicle development, anovulation, amenorrhea, and infertility. Hyperinsulinemia has also been associated high blood pressure and increased clot formation and appears to be a major risk factor for the development of heart disease, stroke and type II diabetes.
Patients with PCOS from insulin resistance are more difficult to treat. They may not respond to clomiphene citrate or may have complications with gonadotropins. This endocrine abnormality can be reversed by treatment with medications that are used for the treatment of adult onset diabetes. The medications include Metformin (Glucophage 500 or 850 mg three times per day or 1000mg twice daily with meals), pioglitazone (Actos 15-30 mg once a day), or rosiglitazone (Avandia 4-8 mg once daily). These medications may reverse the endocrine abnormalities seen with polycystic ovary syndrome within two or three months. They can decrease hair loss, diminish facial and body hair growth, normalize blood pressure, regulate menses, weight loss and normal fertility. Patients may begin to have regular cycles in as little as 60 days and 90% of women will resume regular cycles on their own or with controlled ovarian hyperstimulation within 6 months after beginning treatment with these insulin-lowering medications. This regimen has been shown to help up to 85 percent of these patients ovulate and conceive.
Side effects from these medications are rare but may include abdominal cramping and loose stools which usually subside after the first 2 weeks. Although Metformin, rosiglitazone and pioglitazone lower elevated blood sugar levels in diabetics, when given to nondiabetic patients, they only lower insulin levels. Blood sugar levels will not change. In fact, episodes of "hypoglycemic attacks" appear to be reduced.
METFORMIN (Glucophage)
When first starting Metformin, people will often experience upset stomach or diarrhea, which usually resolves after the first two weeks. The rare side effect of lactic acidosis occurs mainly in patients with abnormal kidney function (creatnine clearance < 60% of normal).
ROSIGLITAZONE, (Avandia), PIOGLITAZONE, (Actos)
Rosiglitaone (Avandia) and pioglitazone (Actos) are metabolized by the liver and should not be used in patients with abnormal liver function. Patients should have liver function tests done every month to monitor function for the first 3 - months of treatment, and then every 6 - 12 months afterwards.
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