Overview
What Is It?
Polycystic ovary syndrome (PCOS) is generally characterized by the presence of polycystic ovaries, hyperandrogenism (the condition caused by excess male hormones or male-like traits) and irregular ovulation and menstruation.
Polycystic ovary syndrome (PCOS) is the most common cause of infertility in reproductive-age women and an important harbinger of metabolic disorders such as diabetes and heart disease. It affects an estimated 5 to 10 percent of females and is associated with an increased risk of diabetes and obesity, and as a result, an increased risk of cardiovascular disease. The syndrome is generally characterized by the presence of polycystic ovaries, hyperandrogenism (the condition caused by excess male hormones or male-like traits) and irregular ovulation and menstruation. The symptoms of PCOS can vary.
The syndrome was previously called Stein-Leventhal Syndrome after the physicians who first characterized it in the 1930s. It usually presents in young women or adolescents, and the main symptoms are irregular or absent periods and excess unwanted facial and/or body hair growth (hirsutism). As the term polycystic ovary syndrome suggests, the syndrome often is accompanied by enlarged ovaries containing multiple small painless "cysts" or tiny follicles about 1/8 to 1/4 inch in diameter.
During a normal menstrual cycle in which a woman ovulates (called an ovulatory cycle), a small number of follicles begin to grow. One becomes the biggest, or dominant, follicle. This dominant follicle then ruptures and releases the egg.
In women with PCOS, however, high levels of hormones called androgens (commonly known as "male hormones") halt the normal hormonal process and the egg's development. These halted or arrested follicles––whose appearance (via an ultrasound) is sometimes likened to a "string of pearls" on the outside border of the ovary––form the "cysts" observed in PCOS. These cysts are not tumors and do not require removal. Treatment of PCOS, instead, is through the use of lifestyle modifications and medication to treat symptoms.
Many, but not all, women with PCOS will have the polycystic-looking ovaries (which are often two to five times larger than normal ovaries) for which the syndrome is named, but it is possible to be diagnosed with the syndrome without having this sign. And not all women with polycystic-appearing ovaries will have PCOS.
While the biochemical imbalances that cause symptoms are becoming better understood, the trigger for PCOS is unknown. Some researchers believe that abnormal levels of the pituitary hormone LH and high levels of male hormones (androgens) prevent the ovaries from functioning normally. Others believe that the origin is in abnormalities in the genes that regulate the production of androgens or the action of insulin.
Some patients with PCOS experience excess insulin production from the pancreas, which can result from insulin resistance. Insulin resistance is a precursor to type 2 diabetes. The high levels of insulin in these women help stimulate the ovaries to overproduce androgens and may be the cause of PCOS in some women.
Insulin resistance in women with PCOS results from the fact that in these women the body's cells don't respond well to insulin. Insulin is a hormone produced by the pancreas. It regulates a range of functions, including controlling blood sugar and fats. With insulin resistance, the pancreas produces excessive amounts of insulin, leading to a condition called hyperinsulinism or hyperinsulinemia.
In addition to stimulating the ovaries to overproduce male hormones (called androgens), high levels of insulin can cause darkening of the skin around the neck and other crease areas, a condition called acanthosis nigricans, often accompanied by skin tags in these areas.
If the pancreas can't produce enough insulin to compensate for the insulin resistance, glucose builds up in the blood, eventually leading to type 2 diabetes.
About 80 percent of obese women with PCOS have insulin resistance by age 40 and about 10 percent develop type 2 diabetes. Insulin resistance and an increased risk of diabetes is also a problem for normal weight women with PCOS, although less so than for obese women. For obese women with PCOS, their treatment plans should incorporate diet and exercise.
Obesity in women with PCOS tends to be centered on the abdomen, a fat distribution pattern linked to increased risk of diabetes, heart disease and high blood pressure.
Up to 50 percent of women with PCOS also have sleep apnea, a condition that causes brief spells where breathing stops during sleep. Sleep apnea can worsen the degree of insulin resistance.
The most visible symptoms of PCOS stem from excessive levels of androgens, such as testosterone, produced by the ovaries and the adrenal glands. Androgens often are called "male hormones," even though they are found in both men and women. They are usually present at higher concentrations in men and are an important factor in determining male traits and reproductive activity. Androgens include testosterone, dihydrotestosterone (DHT), androstenedione and dehydroepiandrosterone (DHEA) or the HS sulfated form (DHEA-S).
Excessive levels of these hormones, a condition called hyperandrogenemia, or their exaggerated action, called hyperandrogensim can lead to some of the most common symptoms of PCOS in women, including:
But such symptoms alone are not enough to support a diagnosis of PCOS. They may only indicate the presence of hyperandrogenism, which can result from several conditions.
Women with PCOS ovulate irregularly and/or infrequently and often have irregular menstrual periods. Inducing a period is important because the hormone progesterone promotes the normal shedding of the uterine lining (i.e., menstruation), preventing the buildup of the uterine lining and reducing the risk of endometrial (uterine) cancer. However, progesterone is secreted by the ovaries only after ovulation occurs.
PCOS often is a cause of infertility due to failure to ovulate.
Women with PCOS are more likely to be overweight or obese, although the exact relationship is unknown. Excess weight worsens PCOS, but researchers do not yet know whether or not having PCOS makes patients more prone to obesity.
It is not surprising that women with PCOS often suffer from poor self image and may experience depression or anxiety.
PCOS is mostly a genetic disorder. For example, an estimated 50 percent of sisters and 40 percent of mothers of patients with PCOS can be affected.
To date there is no cure for PCOS. Health care professionals usually address the most bothersome symptoms. Because of the complexity of the hormonal interactions, you may need to see an endocrinologist or a reproductive endocrinologist (especially if you are infertile and trying to conceive).
Diagnosis
Diagnosis begins with an inventory of signs and symptoms, the most common of which are:
Women with PCOS may have varying combinations of these and other signs and symptoms, but two essential features of the disorder are:
The diagnostic process should include a thorough physical examination and history to check for signs and symptoms of hypothyroidism, Cushing's syndrome (a hormonal disorder in which the adrenal glands malfunction), adrenal hyperplasia (a genetic condition that results in male hormone excess produced by the adrenal glands), and androgen-secreting tumors (of the ovary, adrenal gland, etc.). While there is no single test for PCOS, a health care professional may measure blood levels of the following:
In general, a two-hour glucose tolerance test, where your blood is drawn before you drink a sugary solution and again one and two hours afterward, is best for diabetes predictors in women with PCOS.
These tests should be interpreted carefully by a specialist, such as an endocrinologist or reproductive endocrinologist. The best time to be tested is in the morning just after your menstrual period begins (you may need medication to induce menstruation). Birth control pills might make the tests difficult to interpret because they change the hormonal balance and may mask any abnormalities that may exist in male hormones.
Your health care professional may order ultrasound imaging of the ovaries to look for the characteristic picture of multiple cysts. An ultrasound may also be used to look for abnormalities in the lining of the uterus, called the endometrium.
The ultrasound test usually involves insertion of a probe into the vagina, although a transabdominal ultrasound, in which the ultrasound is passed over your abdomen, can be performed, particularly in women who have never been sexually active.
PCOS is also associated with an increased risk of diabetes and obesity, and as a result, an increased risk of cardiovascular disease. If you have PCOS, you should be tested and treated for insulin resistance, type 2 diabetes, high blood pressure and elevated blood lipids (cholesterol and triglycerides). Women with PCOS who become pregnant should be advised that they are at increased risk of developing gestational diabetes.
Treatment
Treatment of polycystic ovarian syndrome (PCOS) centers on lifestyle modifications and medication. Surgical procedures to destroy or shrink the ovarian cysts are less likely to be performed today given the success of hormonal treatments. If you fail to ovulate with conventional treatment (the fertility drug clomiphene citrate Clomid) and can't, for whatever reason, proceed to gonadotropin shots or in vitro fertilization (IVF), your doctor may recommend an outpatient surgery called laparoscopic ovarian drilling.
Because the primary cause of PCOS is unknown, treatment is directed at the primary symptoms of the disorder, which include excess hair growth, irregular periods and infertility.
Excess hair growth
For some women, the most bothersome symptom is hirsutism (excess facial and/or body hair, often dark and coarse). This symptom, as well as acne and oily skin, stem from the overproduction of androgens. For women with these symptoms, an anti-androgen medication like spironolactone (Aldactone) or flutamide (Eulexin) may be prescribed.
Spironolactone is a diuretic that works by blocking the action of testosterone at the hair follicle. Side effects are generally mild and may include heartburn and upset stomach, sun sensitivity, increased urination and lower blood pressure causing weakness or faintness. At high doses, it can clear oily skin and make unwanted hair finer. Flutamide, a drug used to treat prostate cancer in men, has fewer side effects than spironolactone, although it rarely can cause liver damage. Both spironolactone and flutamide contain an FDA "black box" warning because they may cause birth defects (particularly in a male fetus) if taken while pregnant. Talk to your health care professional about potential risks.
A drug used to treat enlarged prostate and baldness in men––called finasteride (Propecia)––may also be useful in women with hyperandrogenism symptoms, including hirsutism. The drug stops the action of an enzyme called 5-alpha reductase, which converts testosterone to the more powerful dihydrotestosterone. It is not FDA-approved for excess hair growth in women, but it is sometimes used off-label for this purpose. Finasteride, however, can also cause birth defects in a male fetus (pregnant women should not even handle the drug in crushed tablet form). And many insurance companies won't cover the drug for cosmetic reasons.
If you are trying to conceive, you cannot take an anti-androgen medication because it could cross the placenta and cause defects in a male fetus. Usually, anti-androgen medications are used in combination with birth control pills, which not only prevent unplanned pregnancies, but also improve the success of these medications on excess hair growth.
Electrolysis, and possibly lasers, can remove any remaining hairs permanently.
Eflornithine hydrochloride (Vaniqa) may also help slow the hair growth on the face. It works well in about one-third to one-half of women using it. The medication is applied to the face twice a day like a moisturizer. It works by blocking a key enzyme that makes hair grow. Noticeable results take about six to eight weeks. It must be used regularly or the hair will grow back after about eight weeks.
Bear in mind that it can take up to nine months to see effects on hair growth and a year or longer to achieve peak effect. The hair will still be there, but it will generally grow more slowly and be lighter and finer.
Irregular periods
If irregular and/or infrequent menstruation is a problem, birth control pills that contain estrogen and progestin can generally regulate your cycles. Restoring regular periods is essential since it ensures that the lining of the uterus is shed, protecting against uterine cancer. Birth control pills also reduce the production of androgens by the ovaries.
Rare side effects of birth control pills include migraines, nausea and headaches, and, rarely blood clots (especially among smokers and women with persistent high blood pressure), gallbladder disease and high blood pressure.
If you don't want to take a daily medication, talk to your doctor about a course of progestogen (progesterone-like drugs) several times a year to start your periods. It is important to have at least six to eight periods a year to promote shedding of the endometrial lining; buildup can lead to cancer. However, periodic progesterone alone does not help reduce unwanted hair growth as birth control pills do.
Another drug that helps regulate periods in some women with PCOS is the insulin-sensitizing drug metformin (Glucophage). Metformin regulates blood glucose (sugar) levels by reducing the amount of glucose the liver produces, reducing the amount of glucose absorbed from food and reducing the levels of insulin in the blood by helping the insulin that your body produces work better to reduce the amount of glucose already in your blood.
The drug is not FDA-approved for PCOS, but research done so far shows it helps modestly improve ovulation and may reduce androgen levels. If you are among the 10 percent or so of women with PCOS who already have type 2 diabetes, metformin is also a good therapeutic option. Experts aren't sure, however, if metformin is as effective at preventing endometrial cancer in women with PCOS as birth control pills or progesterone.
If you are prescribed metformin, be sure to inform your health care professional of all other medications you are taking, including over-the-counter medicines, to prevent drug interactions.
Infertility
Infertility often is a consequence of PCOS. If you are overweight or obese, the first line of treatment is weight loss; even losing a little bit of weight may stimulate ovulation. Weight loss can also boost the effectiveness of other infertility treatments.
The second line of treatment is the ovulation-stimulating drug clomiphene (Clomid or Serophene), which is used to treat infertile women with ovulation problems. It works by helping the pituitary gland send hormonal signals to stimulate the development of more eggs in the ovaries. Clomiphene stimulates ovulation in about 80 percent of women with PCOS, and about half of these women become pregnant.
If clomiphene doesn't work, your doctor may suggest using gonadotropins or the insulin-sensitizing drug metformin (Glucophage) in combination with clomiphene.
Treatment with gonadotropins—purified solutions of follicle-stimulating hormone (FSH) with or without luteinizing hormone (LH)—may be administered by injection. Because many women with PCOS have elevated LH, some doctors may recommend treatment with FSH alone.
But treatment with gonadotropins, while effective, is more challenging to manage and more expensive. Some women also have some trouble self-administering the injections. Risks include multiple births and ovarian hyperstimulation syndrome. In many patients mild signs and symptoms of hyperstimulation may occur, including bloating, fluid retention, weight gain and a tender stomach. In more severe cases fluid from the bloodstream leaks into the abdominal cavity, causing it to swell, and making the blood thicker. This may lead to breathing difficulties, temporary kidney failure and blood clots. Thus, gonadotropins should only be prescribed by clinicians specifically trained in their use.
Another option for women who fail to ovulate with clomiphene or metformin therapy, or who are unwilling or unable to use gonadotropins (or can't afford to use them), is a surgical procedure known as laparoscopic ovarian drilling.
During this procedure, a surgeon makes a small incision in your abdomen and inserts a laparoscope (a telescope-like instrument attached to a tiny camera). The surgeon then makes other small incisions and inserts surgical equipment that uses electrical or laser energy to burn small holes in the enlarged follicles on the surface of your ovaries. The goal of the procedure is to stimulate ovulation by reducing LH and androgen levels.
Additionally, many women who failed to ovulate with clomiphene or metformin therapy are able to ovulate with these medications after ovarian drilling. The success rates for laparoscopic ovarian drilling appear to be better for patients at or near their ideal body weight, as opposed to those who are obese. Interestingly, women in these studies who are smokers rarely improved with the drilling procedure. Side effects are rare, primarily adhesions, although laparoscopic ovarian surgery requires general anesthesia, which carries its own risks.
Other Approaches
Long-term, nonmedical treatment is geared toward modifying your risk factors for health problems often associated with PCOS, including diabetes, uncontrollable weight gain and heart disease. A healthy, low-sugar, low-starch diet and an exercise program to stabilize your weight can reduce the risk of these conditions.
You can take care of some problems associated with PCOS without medication. Excess hair can be removed by shaving, tweezing, waxing or using depilatory creams, or by electrolysis or laser techniques administered by a trained professional. Since lasers work by attacking a skin pigment, they should be used with caution by darker-skinned women.
If you are overweight and have PCOS, you need to lose weight. Losing even just a small amount of weight can lower androgen and insulin levels, reducing your risk of insulin resistance and diabetes. One study found that when obese women with PCOS lost more than 5 percent of their body weight, their androgen levels dropped and their periods became more regular.
Exercise alone, even without weight loss, is also beneficial since it helps improve insulin sensitivity.
It seems that some PCOS symptoms improve as women near menopause, but some of the complications may persist into or beyond menopause, particularly male pattern baldness or thinning hair, which sometimes gets worse after menopause. The risk for heart attack, stroke and diabetes also increases in menopause in women with PCOS. In cases where PCOS symptoms persist, the best recommendation is to monitor cholesterol, triglycerides and blood pressure, as well as glucose and insulin levels.
Prevention
There is no known way to prevent polycystic ovary syndrome (PCOS). Researchers are still working to understand the underlying causes. However, if you have PCOS there is a high likelihood that your daughter or sister will have the disorder. There are steps you can take to prevent some of the worst consequences of the disorder––diabetes, uterine cancer, high blood pressure and high levels of blood lipids (a risk factor for heart disease).
If you do not menstruate, inducing menstruation with a progesterone-like agent should be a top priority. During menstruation, the endometrial lining is shed in response to withdrawal of the progestogen hormone. Without this shedding, your risk of uterine cancer rises significantly. Birth control pills, which combine estrogen and progestin, can restore regular periods. If you don't want to take a daily medication, a course of progesterone, such as medroxyprogesterone acetate, micronized progesterone or norethindrone acetate, taken for 10 to 14 days every one to three months, may help.
If you are overweight, losing weight is a big step toward lowering your risk for diabetes and heart disease. Losing weight can help restore regular periods and improve other hormonal imbalances, but weight loss is often an incomplete solution to PCOS.
Facts to Know
Questions to Ask
Review the following Questions to Ask about polycystic ovary syndrome (PCOS) so you're prepared to discuss this important health issue with your health care professional.
Key Q&A
Organizations and Support
For information and support on coping with Polycystic Ovary Syndrome, please see the recommended organizations, books and Spanish-language resources listed below.
American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org
Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org
Polycystic Ovarian Syndrome Association
Website: http://www.pcosupport.org
Address: P.O. Box 3403
Englewood, CO 80111
Hotline: 1-877-775-PCOS (1-877-775-7267)
Email: info@pcosupport.org
A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker
Pocket PCOS: A Quick and Practical Guide to Polycystic Ovary Syndrome with Personal Testimonies
by Christopher Hearn and M.D. Shahab S. Minassian
Medline Plus: Ovarian Cysts
Website: http://www.nlm.nih.gov/medlineplus/spanish/ovariancysts.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov
American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/gynecologic/279.printerview.html
[Section: Diagnosis]
Diagnosis
Diagnosis begins with an inventory of signs and symptoms, the most common of which are:
Women with PCOS may have varying combinations of these and other signs and symptoms, but two essential features of the disorder are:
The diagnostic process should include a thorough physical examination and history to check for signs and symptoms of hypothyroidism, Cushing's syndrome (a hormonal disorder in which the adrenal glands malfunction), adrenal hyperplasia (a genetic condition that results in male hormone excess produced by the adrenal glands), and androgen-secreting tumors (of the ovary, adrenal gland, etc.). While there is no single test for PCOS, a health care professional may measure blood levels of the following:
In general, a two-hour glucose tolerance test, where your blood is drawn before you drink a sugary solution and again one and two hours afterward, is best for diabetes predictors in women with PCOS.
These tests should be interpreted carefully by a specialist, such as an endocrinologist or reproductive endocrinologist. The best time to be tested is in the morning just after your menstrual period begins (you may need medication to induce menstruation). Birth control pills might make the tests difficult to interpret because they change the hormonal balance and may mask any abnormalities that may exist in male hormones.
Your health care professional may order ultrasound imaging of the ovaries to look for the characteristic picture of multiple cysts. An ultrasound may also be used to look for abnormalities in the lining of the uterus, called the endometrium.
The ultrasound test usually involves insertion of a probe into the vagina, although a transabdominal ultrasound, in which the ultrasound is passed over your abdomen, can be performed, particularly in women who have never been sexually active.
PCOS is also associated with an increased risk of diabetes and obesity, and as a result, an increased risk of cardiovascular disease. If you have PCOS, you should be tested and treated for insulin resistance, type 2 diabetes, high blood pressure and elevated blood lipids (cholesterol and triglycerides). Women with PCOS who become pregnant should be advised that they are at increased risk of developing gestational diabetes.
[Section: Treatment]
Treatment
Treatment of polycystic ovarian syndrome (PCOS) centers on lifestyle modifications and medication. Surgical procedures to destroy or shrink the ovarian cysts are less likely to be performed today given the success of hormonal treatments. If you fail to ovulate with conventional treatment (the fertility drug clomiphene citrate Clomid) and can't, for whatever reason, proceed to gonadotropin shots or in vitro fertilization (IVF), your doctor may recommend an outpatient surgery called laparoscopic ovarian drilling.
Because the primary cause of PCOS is unknown, treatment is directed at the primary symptoms of the disorder, which include excess hair growth, irregular periods and infertility.
Excess hair growth
For some women, the most bothersome symptom is hirsutism (excess facial and/or body hair, often dark and coarse). This symptom, as well as acne and oily skin, stem from the overproduction of androgens. For women with these symptoms, an anti-androgen medication like spironolactone (Aldactone) or flutamide (Eulexin) may be prescribed.
Spironolactone is a diuretic that works by blocking the action of testosterone at the hair follicle. Side effects are generally mild and may include heartburn and upset stomach, sun sensitivity, increased urination and lower blood pressure causing weakness or faintness. At high doses, it can clear oily skin and make unwanted hair finer. Flutamide, a drug used to treat prostate cancer in men, has fewer side effects than spironolactone, although it rarely can cause liver damage. Both spironolactone and flutamide contain an FDA "black box" warning because they may cause birth defects (particularly in a male fetus) if taken while pregnant. Talk to your health care professional about potential risks.
A drug used to treat enlarged prostate and baldness in men––called finasteride (Propecia)––may also be useful in women with hyperandrogenism symptoms, including hirsutism. The drug stops the action of an enzyme called 5-alpha reductase, which converts testosterone to the more powerful dihydrotestosterone. It is not FDA-approved for excess hair growth in women, but it is sometimes used off-label for this purpose. Finasteride, however, can also cause birth defects in a male fetus (pregnant women should not even handle the drug in crushed tablet form). And many insurance companies won't cover the drug for cosmetic reasons.
If you are trying to conceive, you cannot take an anti-androgen medication because it could cross the placenta and cause defects in a male fetus. Usually, anti-androgen medications are used in combination with birth control pills, which not only prevent unplanned pregnancies, but also improve the success of these medications on excess hair growth.
Electrolysis, and possibly lasers, can remove any remaining hairs permanently.
Eflornithine hydrochloride (Vaniqa) may also help slow the hair growth on the face. It works well in about one-third to one-half of women using it. The medication is applied to the face twice a day like a moisturizer. It works by blocking a key enzyme that makes hair grow. Noticeable results take about six to eight weeks. It must be used regularly or the hair will grow back after about eight weeks.
Bear in mind that it can take up to nine months to see effects on hair growth and a year or longer to achieve peak effect. The hair will still be there, but it will generally grow more slowly and be lighter and finer.
Irregular periods
If irregular and/or infrequent menstruation is a problem, birth control pills that contain estrogen and progestin can generally regulate your cycles. Restoring regular periods is essential since it ensures that the lining of the uterus is shed, protecting against uterine cancer. Birth control pills also reduce the production of androgens by the ovaries.
Rare side effects of birth control pills include migraines, nausea and headaches, and, rarely blood clots (especially among smokers and women with persistent high blood pressure), gallbladder disease and high blood pressure.
If you don't want to take a daily medication, talk to your doctor about a course of progestogen (progesterone-like drugs) several times a year to start your periods. It is important to have at least six to eight periods a year to promote shedding of the endometrial lining; buildup can lead to cancer. However, periodic progesterone alone does not help reduce unwanted hair growth as birth control pills do.
Another drug that helps regulate periods in some women with PCOS is the insulin-sensitizing drug metformin (Glucophage). Metformin regulates blood glucose (sugar) levels by reducing the amount of glucose the liver produces, reducing the amount of glucose absorbed from food and reducing the levels of insulin in the blood by helping the insulin that your body produces work better to reduce the amount of glucose already in your blood.
The drug is not FDA-approved for PCOS, but research done so far shows it helps modestly improve ovulation and may reduce androgen levels. If you are among the 10 percent or so of women with PCOS who already have type 2 diabetes, metformin is also a good therapeutic option. Experts aren't sure, however, if metformin is as effective at preventing endometrial cancer in women with PCOS as birth control pills or progesterone.
If you are prescribed metformin, be sure to inform your health care professional of all other medications you are taking, including over-the-counter medicines, to prevent drug interactions.
Infertility
Infertility often is a consequence of PCOS. If you are overweight or obese, the first line of treatment is weight loss; even losing a little bit of weight may stimulate ovulation. Weight loss can also boost the effectiveness of other infertility treatments.
The second line of treatment is the ovulation-stimulating drug clomiphene (Clomid or Serophene), which is used to treat infertile women with ovulation problems. It works by helping the pituitary gland send hormonal signals to stimulate the development of more eggs in the ovaries. Clomiphene stimulates ovulation in about 80 percent of women with PCOS, and about half of these women become pregnant.
If clomiphene doesn't work, your doctor may suggest using gonadotropins or the insulin-sensitizing drug metformin (Glucophage) in combination with clomiphene.
Treatment with gonadotropins—purified solutions of follicle-stimulating hormone (FSH) with or without luteinizing hormone (LH)—may be administered by injection. Because many women with PCOS have elevated LH, some doctors may recommend treatment with FSH alone.
But treatment with gonadotropins, while effective, is more challenging to manage and more expensive. Some women also have some trouble self-administering the injections. Risks include multiple births and ovarian hyperstimulation syndrome. In many patients mild signs and symptoms of hyperstimulation may occur, including bloating, fluid retention, weight gain and a tender stomach. In more severe cases fluid from the bloodstream leaks into the abdominal cavity, causing it to swell, and making the blood thicker. This may lead to breathing difficulties, temporary kidney failure and blood clots. Thus, gonadotropins should only be prescribed by clinicians specifically trained in their use.
Another option for women who fail to ovulate with clomiphene or metformin therapy, or who are unwilling or unable to use gonadotropins (or can't afford to use them), is a surgical procedure known as laparoscopic ovarian drilling.
During this procedure, a surgeon makes a small incision in your abdomen and inserts a laparoscope (a telescope-like instrument attached to a tiny camera). The surgeon then makes other small incisions and inserts surgical equipment that uses electrical or laser energy to burn small holes in the enlarged follicles on the surface of your ovaries. The goal of the procedure is to stimulate ovulation by reducing LH and androgen levels.
Additionally, many women who failed to ovulate with clomiphene or metformin therapy are able to ovulate with these medications after ovarian drilling. The success rates for laparoscopic ovarian drilling appear to be better for patients at or near their ideal body weight, as opposed to those who are obese. Interestingly, women in these studies who are smokers rarely improved with the drilling procedure. Side effects are rare, primarily adhesions, although laparoscopic ovarian surgery requires general anesthesia, which carries its own risks.
Other Approaches
Long-term, nonmedical treatment is geared toward modifying your risk factors for health problems often associated with PCOS, including diabetes, uncontrollable weight gain and heart disease. A healthy, low-sugar, low-starch diet and an exercise program to stabilize your weight can reduce the risk of these conditions.
You can take care of some problems associated with PCOS without medication. Excess hair can be removed by shaving, tweezing, waxing or using depilatory creams, or by electrolysis or laser techniques administered by a trained professional. Since lasers work by attacking a skin pigment, they should be used with caution by darker-skinned women.
If you are overweight and have PCOS, you need to lose weight. Losing even just a small amount of weight can lower androgen and insulin levels, reducing your risk of insulin resistance and diabetes. One study found that when obese women with PCOS lost more than 5 percent of their body weight, their androgen levels dropped and their periods became more regular.
Exercise alone, even without weight loss, is also beneficial since it helps improve insulin sensitivity.
It seems that some PCOS symptoms improve as women near menopause, but some of the complications may persist into or beyond menopause, particularly male pattern baldness or thinning hair, which sometimes gets worse after menopause. The risk for heart attack, stroke and diabetes also increases in menopause in women with PCOS. In cases where PCOS symptoms persist, the best recommendation is to monitor cholesterol, triglycerides and blood pressure, as well as glucose and insulin levels.
[Section: Prevention]
Prevention
There is no known way to prevent polycystic ovary syndrome (PCOS). Researchers are still working to understand the underlying causes. However, if you have PCOS there is a high likelihood that your daughter or sister will have the disorder. There are steps you can take to prevent some of the worst consequences of the disorder––diabetes, uterine cancer, high blood pressure and high levels of blood lipids (a risk factor for heart disease).
If you do not menstruate, inducing menstruation with a progesterone-like agent should be a top priority. During menstruation, the endometrial lining is shed in response to withdrawal of the progestogen hormone. Without this shedding, your risk of uterine cancer rises significantly. Birth control pills, which combine estrogen and progestin, can restore regular periods. If you don't want to take a daily medication, a course of progesterone, such as medroxyprogesterone acetate, micronized progesterone or norethindrone acetate, taken for 10 to 14 days every one to three months, may help.
If you are overweight, losing weight is a big step toward lowering your risk for diabetes and heart disease. Losing weight can help restore regular periods and improve other hormonal imbalances, but weight loss is often an incomplete solution to PCOS.
[Section: Facts to Know]
Facts to Know
[Section: Questions to Ask]
Questions to Ask
Review the following Questions to Ask about polycystic ovary syndrome (PCOS) so you're prepared to discuss this important health issue with your health care professional.
[Section: Key Q&A]
Key Q&A
[Section: Organizations and Support]
Organizations and Support
For information and support on coping with Polycystic Ovary Syndrome, please see the recommended organizations, books and Spanish-language resources listed below.
American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org
Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org
Polycystic Ovarian Syndrome Association
Website: http://www.pcosupport.org
Address: P.O. Box 3403
Englewood, CO 80111
Hotline: 1-877-775-PCOS (1-877-775-7267)
Email: info@pcosupport.org
A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker
Pocket PCOS: A Quick and Practical Guide to Polycystic Ovary Syndrome with Personal Testimonies
by Christopher Hearn and M.D. Shahab S. Minassian
Medline Plus: Ovarian Cysts
Website: http://www.nlm.nih.gov/medlineplus/spanish/ovariancysts.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov
American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/gynecologic/279.printerview.html
"Patient information: Polycystic ovary syndrome." Uptodate.com. May 2011. http://www.uptodate.com/contents/patient-information-polycystic-ovary-syndrome-pcos
Accessed September 2011.
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