polycystic ovarian syndrome (pcos)Polycystic ovarian syndrome is a condition in which there is a hormonal imbalance within the ovaries.
Normally the ovary produces oestrogen (E) (the female hormone), testosterone (T) (the male hormone) and progesterone (P) (the pregnancy hormone). P is only produced after ovulation or an egg has been released. In this condition, E may be produced in normal amounts, T may sometimes be produced in excess and P may not be produced every month because the woman may not ovulate every month. There may be an imbalance in the amounts of E versus T that may prevent ovulation. We are still unsure as to why women develop PCOS. In some women it may run in families, in other women it may only occur if they are overweight and will then correct itself once they lose weight.
Women who have PCOS may have the following problems:
- infertility due to lack of ovulation,
- excessive or male pattern hair growth (hirsutism) due to imbalance between E and T,
- irregular menstrual cycles and heavy bleeding (cycles which are either less than 21 days or more than 35 days apart) due to lack of ovulation, and
- obesity. Most women will present with the problems of abnormal bleeding, hirsutism, infertility or less commonly with obesity. Some women with PCOS may have a higher than normal miscarriage rate if they become pregnant.
The diagnosis of PCOS is made primarily on the woman's presenting history and examination. The diagnosis can be confirmed on ultrasound or by measuring the woman's hormonal levels. If the ultrasound and the blood tests are normal it does not mean that the woman does not have the condition. However, it has also been found that women who do not have problems with their periods or of excessive hair growth can have ovaries which on ultrasound have the appearance of being polycystic.
The treatment of a woman with PCOS will depend on the presenting problems. For example, the problem of hirsutism will prevent treatment for infertility.
If a woman presents with irregular heavy bleeding, the oral contraceptive pill (OCP) is the treatment of choice, both to regulate the cycle and to prevent over growth of the endometrium (lining of the womb). P can also be given to replace what is not being produced monthly. If hirsutism is the problem it can be treated using the OCP as well as with drugs that act against T. If these drugs are used it is most important that the woman use a reliable form of contraception as they may cause genital abnormalities in a male baby if the woman becomes pregnant.
If infertility is the problem then clomiphene citrate (CC) (Clomid or Serophene) given orally for 5 days early in the menstrual cycle may induce ovulation. Ovulation can be induced in 80% of women using CC and pregnancy rates approach those seen in the normal population (20-25% per month) provided that there are no other factors affecting fertility. The commonest side-effect with CC is hot flushes. The multiple pregnancy rate with CC is 5% and the majority of these multiple pregnancies are twin pregnancies.
 If CC fails to induce ovulation at maximal doses or if the woman has tried CC for up to 6 cycles in which she has ovulated but has not become pregnant, follicle stimulating hormone (FSH) at low doses may be given. Prior to using these drugs the treating doctor will want to (if she/he has not already done so) make sure that the woman's Fallopian tubes are open and that her pelvis is normal, by performing a laparoscopy and hysteroscopy. These drugs are given by injection and when the woman uses these drugs she needs to be monitored using blood tests and ultrasounds to make sure that the drugs are not causing her to develop too many eggs. The aim when these drugs are used is to cause only one egg to develop (similar to in a natural cycle).
Nevertheless, the multiple pregnancy rate may be 20-30% with 80% of these multiple pregnancies being twin pregnancies.
Weight loss is also of paramount importance. The disease process may be reversed with loss of weight and there is also evidence that the higher miscarriage rate may decrease to that in the general population with weight loss. A dietician may be required.
An operation called ovarian drilling, performed at laparoscopy, can also be used to treat women with PCOS. This operation is usually reserved for women who want to be pregnant, and who have not ovulated on CC. In these women it may be used as an alternative to HMG or FSH. During this procedure the ovary is cauterized by drilling into it in a number of spots. We do not know exactly why this procedure works. If the operation is successful the effect may be long lasting.
In a small number of women, PCOS can be a very severe disease in that it can lead to the development of diabetes with all its complications. If the doctor suspects that the woman has this type of illness, she may need to undergo testing to make sure that she is not currently a diabetic. If diabetes is diagnosed weight loss, diet and the possible use of tablets may be necessary.
TO find out more about PCO and PCOS please click on the link below:
http://www.managingpcos.org.au/content/view/13/1/
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