PCOS is a disorder involving irregular menstrual periods and excess androgen level. The ovaries develop cysts (above right) and may failed to release eggs.
Definition
Polycystic ovary syndrome (PCOS) is a common condition characterized by irregular menstrual periods, excess hair growth and obesity, though it can affect women in a variety of ways.
The exact cause of polycystic ovary syndrome is unknown, but the condition stems from a disruption in the monthly reproductive cycle. The name polycystic ovary syndrome comes from the appearance of the ovaries in some women with the disorder — large and studded with numerous cysts (polycystic).
Polycystic ovary syndrome affects about one in 10 women in the United States and is the leading cause of infertility in women. Early diagnosis and treatment of polycystic ovary syndrome can help reduce the risk of long-term complications, which include diabetes and heart disease.
Symptoms
Polycystic ovary syndrome
Women with polycystic ovary syndrome usually have at least several of the many signs and symptoms associated with PCOS, including:
Irregular or no menstruation.
This is the most common characteristic. Irregular menstruation means having menstrual cycles that occur at intervals longer than 35 days or fewer than eight times a year. The condition may begin in adolescence with the onset of menstruation, or it may appear later after a weight gain.
Signs of excess androgen.
Elevated levels of male hormones may result in physical signs, such as long, coarse hair on your face, chest, lower abdomen, back, upper arms or upper legs (hirsutism); acne; and male-pattern baldness (alopecia). However, not all women who have polycystic ovary syndrome have physical signs of androgen excess.
Enlarged ovaries with multiple cysts.
Your doctor may detect ovarian cysts by ultrasound. However, you may have ovaries with multiple cysts but still not have polycystic ovary syndrome. And you may have PCOS but have ovaries that appear normal.
Infertility.
Polycystic ovary syndrome is the most common cause of female infertility in the United States.
Obesity.
It's estimated that about half of women with polycystic ovary syndrome are obese.
Skin tags.
These small, excess growths of skin that are usually found on your neck or in your armpit are common in women with PCOS.
Prediabetes or type 2 diabetes.
The ability to use insulin effectively is impaired in PCOS and can result in high blood sugar levels and diabetes. Prediabetes is also called impaired glucose tolerance.
Acanthosis nigricans.
This is the medical term for darkened, velvety skin on the nape of your neck, armpits, inner thighs, vulva or under your breasts.
Additionally, the following are more likely to occur in women with PCOS:
* High blood pressure
* High blood cholesterol
* Elevated levels of C-reactive protein, which may be associated with cardiovascular problems
* Nonalcoholic steatohepatitis, a liver disease
* Sleep apnea
Causes
The intricate process of a woman's reproductive cycle is regulated by fluctuating levels of hormones produced by the pituitary gland in your brain, including luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and by your ovaries.
The ovaries secrete the female hormones estrogen and progesterone and also produce some androgens, the so-called male hormones. Androgens include testosterone, androstenedione and dehydroepiandrosterone (DHEA).
In polycystic ovary syndrome, your body produces an excess of androgens, and your ratio of LH to FSH is often abnormally high. The process of ovaries releasing eggs (ovulation) occurs less frequently than normal (oligo-ovulation), or the ovaries don't release eggs at all (anovulation). In the absence of ovulation, the menstrual cycle is irregular or absent.
Doctors don't know the cause of polycystic ovary syndrome, but research suggests a link to excess insulin, the hormone produced in the pancreas that allows cells to use sugar (glucose), your body's primary energy supply. By several mechanisms, excess insulin is thought to boost androgen production by your ovaries. Studies also indicate that genetic factors may play a role in PCOS.
When to seek medical advice
Early diagnosis and treatment of polycystic ovary syndrome may help reduce your risk of long-term complications, such as diabetes and heart disease.
Talk with your doctor if you have irregular, scant or no menstrual periods, are overweight, and have acne or excess facial hair growth. Your doctor may refer you to a doctor who specializes in hormonal disorders (endocrinologist).
Tests and diagnosis
Pelvic examination
As part f the pelvic examination, your doctor will insert two gloved fingers inside your vagina. While simultaneously pressing down on your abdomen, he or she can examine your uterus, ovaries and other organs.
There's no specific test to definitively diagnose polycystic ovary syndrome. The diagnosis is one of exclusion, which means your doctor considers all of your signs and symptoms and then rules out other possible disorders.
Besides a complete physical examination, including a pelvic examination, other tests you may have include:
Blood tests.
Your blood may be drawn for laboratory tests to measure levels of several hormones. These may include testosterone, DHEA sulfate, luteinizing hormone (LH), follicle-stimulating hormone (FSH), 17-hydroxy progesterone, prolactin, and thyroid-stimulating hormone (TSH), which triggers the release of thyroid hormone from the thyroid gland. Additional blood testing may include fasting glucose, cholesterol and triglyceride levels.
Ultrasound.
Your doctor may request a pelvic ultrasound to check your ovaries and the thickness of the lining of your uterus. Ultrasound exams are painless. While you relax on a bed or examining table, a wand-like device (transducer) is placed on your body or in your vagina (transvaginal ultrasound). It emits inaudible sound waves that are translated into images on a computer.
Complications
Having polycystic ovary syndrome puts you at increased risk of:
* Type 2 diabetes
* High blood pressure
* Increased triglycerides
* Decreased high-density lipoprotein (HDL) cholesterol, the so-called "good" cholesterol
* Cardiovascular disease
* Metabolic syndrome, a cluster of signs and symptoms that indicate a significantly increased risk of cardiovascular disease
Because PCOS disrupts the reproductive cycle and exposes the uterus to a constant supply of estrogen, women with PCOS are at risk of:
*Abnormal uterine bleeding
* Cancer of the uterine lining (endometrial cancer)
Pregnancy concerns
You may need treatment with fertility medications to become pregnant if you have polycystic ovary syndrome. During pregnancy, you may be at increased risk of gestational diabetes and pregnancy-induced high blood
Treatments and drugs
Polycystic ovary syndrome treatment generally focuses on management of your individual main concerns, such as infertility, hirsutism, acne or obesity.
Long term, the most important aspect of treatment is managing cardiovascular risks, such as obesity, high blood cholesterol, diabetes and high blood pressure. To help guide ongoing treatment decisions, your doctor will likely want to see you for regular visits to perform a physical examination, measure your blood pressure and obtain fasting glucose and lipid levels.
You may benefit from counseling about healthy-eating choices and regular exercise. This is particularly important if you're overweight. Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels, and may restore ovulation. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian.
Your doctor may prescribe one or more medications to help manage the symptoms and risks associated with PCOS.
Medications for regulating your menstrual cycle
If you're not trying to become pregnant, your doctor may prescribe low-dose oral contraceptives that combine synthetic estrogen and progesterone. They decrease androgen production and give your body a break from the effects of continuous estrogen. This decreases your risk of endometrial cancer and corrects abnormal bleeding.
An alternative approach is taking progesterone for seven to 10 days each month. This regulates your menstrual cycle and offers protection against endometrial cancer, but it doesn't improve androgen levels.
Your doctor also may prescribe metformin (Glucophage, Glucophage XR), an oral medication for type 2 diabetes that treats insulin resistance. This drug is still being studied as a treatment for polycystic ovary syndrome, but research has demonstrated that it improves ovulation and may reduce androgen levels. However, doctors don't yet know if metformin offers the same protection against endometrial cancer as does treatment with oral contraceptives or with progesterone alone.
Medications for reducing excessive hair growth
Your doctor may add a medication specifically targeted at countering the effects of excess androgen. Spironolactone (Aldactone) blocks the effects of androgen and reduces new androgen production. For those reasons, the drug isn't recommended if you're pregnant or planning to become pregnant. Spironolactone is also a diuretic and may cause you to urinate more frequently.
Your doctor might also prescribe eflornithine (Vaniqa), a prescription cream that slows facial hair growth in women. This medication is effective for about one-third of the women who use it. Avoid using this medication during pregnancy.
Medications for achieving pregnancy
To become pregnant, you may need a medication to trigger ovulation. Clomiphene (Clomid, Serophene) is an oral anti-estrogen medication that you take in the first part of your menstrual cycle. If clomiphene alone isn't effective, your doctor may add metformin to help trigger ovulation.
A study published in the New England Journal of Medicine compared the use of clomiphene and metformin, as well as a combination of the two medications, for achieving pregnancy. The study found that clomiphene was significantly more effective at helping women conceive than was metformin alone. About 80 percent of women are able to conceive using clomiphene, and it's estimated that 50 percent of women taking clomiphene have a baby.
If you don't become pregnant using clomiphene and metformin, your doctor may recommend using gonadotropins — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) medications that are administered by injection. Because many women with PCOS have elevated levels of LH, your doctor may recommend treatment with FSH alone.
With clomiphene or gonadotropins, the risk of multiple births — twins or more — is increased.
Surgery
If medications don't help you become pregnant, your doctor rarely may recommend an outpatient surgery called laparoscopic ovarian drilling.
In this procedure, a surgeon makes a small incision in your abdomen and inserts a tube attached to a tiny camera (laparoscope). The camera provides the surgeon with detailed images of your ovaries and neighboring pelvic organs. The surgeon then inserts surgical instruments through other small incisions and uses electrical or laser energy to burn holes in enlarged follicles on the surface of the ovaries. The goal is to stimulate ovulation by reducing levels of LH and androgen hormones.
Hair removal
Several options besides prescription medications exist for hair removal. They include shaving, plucking and over-the-counter remedies such as waxes, gels, creams and lotions (depilatories). However, depilatories may irritate your skin, so follow package directions and on first use, apply the product to an inconspicuous area to determine if it's suitable for you. The results may last several weeks, then you must repeat treatment.
Options for longer lasting hair removal include:
Electrolysis.
To permanently remove excess hair, some women undergo electrolysis in addition to medical therapy. A fine needle is inserted into the hair follicle and electric current is applied to kill the follicle. Because only one follicle can be treated at a time, this method isn't useful for large areas of the body. Several treatments are usually necessary. Scarring or, rarely, skin infections may occur. Home electrolysis kits usually are ineffective because the hair follicle is deep in the skin, so seek care with an experienced, certified electrologist.
Laser therapy.
Laser hair removal systems use laser light — an intense, pulsating beam of light — to remove unwanted hair. Laser hair removal is effective on short, visible hair. Before the procedure, you shave the area to be treated, and allow it to grow to a stubble. Your doctor may use multiple treatments to target the affected areas. After several months, laser procedures permanently reduce one-third or more of the hair in the targeted area. Even after multiple treatments, however, you may experience some hair regrowth, although the new hair may be finer and lighter in color.
Lifestyle and home remedies
You may hear conflicting advice from media, support groups and health care professionals on the role of diet in weight management. Much of the disagreement focuses on carbohydrates.
Carbohydrates are long chains of glucose, a type of sugar. Your digestive system splits these chains into small sugar molecules that enter your bloodstream and trigger the release of insulin.
Low-fat, high-carbohydrate diets that have been popular in recent years may increase insulin levels, so some health and nutrition advocates advise women with polycystic ovary syndrome to follow a low-carbohydrate diet. However, a diet that calls for increased protein to compensate for decreased carbohydrates may spike your intake of saturated fats, elevating your blood cholesterol levels and increasing your risk of cardiovascular disease. Research hasn't demonstrated that a diet high in protein offers more benefit to women with PCOS than does a diet high in carbohydrates.
Choose complex carbohydrates
Carbohydrates provide many important nutrients, so don't severely restrict them. Instead, choose complex carbohydrates, which are high in fiber. The more fiber in a food, the more slowly it's digested and the more slowly your blood sugar levels rise. High-fiber carbohydrates include whole-grain breads and cereals, whole-wheat pasta, bulgur, barley, brown rice and beans. Limit less healthy, simple carbohydrates such as soda, excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.
Additional research may determine which specific dietary approach is best, but it's clear that losing weight by reducing total calorie intake benefits the overall health of women with polycystic ovary syndrome. Work with your doctor and registered dietitian to determine the best dietary plan for you.
Get your exercise
Exercise helps lower your blood sugar levels. For women with polycystic ovary syndrome, an increase in daily physical activity and participation in a regular exercise regimen are essential for treating or preventing insulin resistance and for helping weight-control efforts.
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