Neelima Chu, MD
TCOYD Newsletter, Vol. 23, 2007

Polycystic ovary syndrome (PCOS) is a hormone disorder that occurs in 5 to 10 percent of women. The exact cause of PCOS is not completely understood. There is debate about whether the cause of PCOS is primarily a disorder of pituitary (the part of the brain that secretes hormones that affect the ovaries) or a disorder originating directly from ovarian and/or adrenal glands. In addition, there is also evidence that PCOS may be directly related to a condition called the metabolic syndrom and/or type 2 diabetes.

Symptoms

It is believed that abnormal levels of the pituitary hormones and high levels of male hormones (androgens) interfere with normal function of the ovaries. These changes in hormone levels cause the classic symptoms of PCOS. The symptoms may include irregular menstrual periods (long cycles, heavy bleeding or no periods at all), abnormal hair growth (on the face, chest and lower abdomen), balding in some women and acne. Women with PCOS may also have polycystic ovaries on pelvic ultrasonography, infertility due to lack of ovulation, obesity, and insulin resistance (elevated insulin levels). The key ovarian findings in PCOS include the presence of 8 to 10 small (2 to 8 mm) follicles in a peripheral array around the ovary. The ovarian volume is also increased on average(1). This classic appearance does not refer to large cysts that might rupture or cause pain. Symptoms of PCOS usually begin around the time of puberty, however, since hormonal changes differ from woman to woman, some may not develop symptoms until adulthood.

PCOS & Diabetes

Patients with PCOS have a high prevalence of defects in insulin secretion, insulin sensitivity, and glucose intolerance. Those women who have high insulin levels may eventually progress to having abnormal glucose levels or type 2 diabetes. Approximately 10 percent of women with PCOS will have type 2 diabetes by 40 years of age, and about one-third will have an abnormal glucose tolerance test(2). There is an apparent increase in PCOS prevalence in type 1 diabetes as well. The small amount of insulin used by type 1 diabetics can stimulate the ovaries and the adrenal gland to produce excess androgens. This rise in androgen levels can lead to an increase in hair growth and irregular menstrual cycles even in type 1 diabetics. In addition, nearly one-half of patients with PCOS have a parent with diabetes.

Diagnosis

The diagnosis of PCOS is made based upon the signs and symptoms. There is no specific blood test or scan that can make the diagnosis. To make the diagnosis, it is required to show menstrual cycle irregularity, evidence of elevated androgen levels in the blood or physical exam findings of increased hair growth, acne, and male pattern hair loss. Prior to treatment, it is important to rule out any other medical conditions that may also cause irregular periods and abnormal hair growth.

Some laboratory tests that may be done to evaluate for PCOS include: testosterone levels, serum dehydroepiandrosterone sulfate (DHEA-S), LH, FSH. Since approximately 45 percent of women with PCOS have abnormal glucose levels or type 2 diabetes(2), a fasting glucose or oral glucose tolerance test and fasting cholesterol levels may be performed. Ultrasound appearance of PCOS is nonspecific and has been found in other conditions with mild forms of hyperandrogenism and insulin resistance. Therefore, it cannot be used as a diagnostic tool.

Treatments

There is no cure for PCOS, but treatment is very important to prevent further health problems which include type 2 diabetes, heart disease, sleep apnea, uterine cancer and nonalcoholic steatohepatitis (fatty liver). The treatment depends on the severity of the disease. If pregnancy is not an issue, then treatment includes using birth control pills to regulate the menstrual cycles. Regular menstrual cycles are important to reduce the risk for uterine cancer. Oral contraceptive pills also reduce the production of male hormones, which may improve increased hair growth and acne. Another method to treat menstrual irregularity is to take a hormone called progestin for 10 to 14 days every one to three months. This will cause a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hair growth and acne). It does, however, reduce the risk of uterine cancer.

In addition to hormonal medications, all treatments that lower insulin levels improve excess ovarian androgen levels and aid in ovulation. Metformin may be used to treat the insulin abnormalities associated with PCOS. Metformin can decrease the ovaries’ production of male hormones and reestablish the body's normal hormone balance. That can improve some signs and symptoms of PCOS.

For women who desire pregnancy, weight loss is the first recommendation. But, if they are unable to lose weight or weight loss does not restore normal menstrual cycles, fertility drugs may be used.

Other treatment options include anti-testosterone medications and prescription creams to lessen the hair growth. Excess hair can be removed by shaving or use of depilatories, electrolysis, or laser therapy. Hair loss can be treated with medications in some situations, although medications are not usually as effective in women as they are in men. Hair replacement and wigs may be considered as possible options.

Ultimately, weight loss is very critical for women with PCOS. Even modest weight loss (5 to 10 percent of the body weight) may result in restoration of normal cycles and improvement in insulin and glucose levels.

For more information, the following web sites are very helpful:

National Library of Medicine
The Hormone Foundation
Polycystic Ovary Syndrome Association

References: 1. Buggs C, Rosenfield RL. Polycystic Ovary Syndrome in Adolescence. Endocrinology and Metabolism Clinics. Volume 34, Issue 3 (September 2005):677-705. 2. Ehrmann DA, Barnes RB, Rosenfield RL, Cavaghan M, Imperial J. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care. Jan 1999; 22(1): 141-146.

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