Health Column: Polycystic Ovary Syndrome: Unveiling more than the ovary

By Christian S. Pope, DO, FACOG
Diplomate, American Board of Obstetrics and Gynecology
HealthCare for Women Inc., New Bedford and Mattapoisett

Dr. Pope practices at St. Luke's Hospital, the New Bedford site of Southcoast Hospitals Group. He can be reached at 508-999-6245.

Dr. Pope is a featured columnist for The Standard-Times on women's health topics. Check out Dr. Pope's column the first Tuesday of every month at www.southcoasttoday.com.

Polycystic ovarian syndrome (PCOS) is a disorder characterized by laboratory and/or clinical findings of higher levels of androgens (male sex hormones), difficulty with ovulating and menstrual irregularity, and polycystic appearance to ovaries on ultrasound. Its prevalence is nearly 10 percent among reproductive-age women and may represent the largest underappreciated segment of the female population at risk for cardiovascular disease.

What are some of the symptoms of PCOS?

Most women suffering from PCOS present with one or more of the following symptoms or characteristics: irregular periods, excessive facial hair, alopecia (loss of hair), high levels of androgens or specific hormones on lab testing, and obesity; although as many as 20 percent of women with PCOS are not obese. Many women also present with a variety of menstrual related complaints, from not having a period for years to heavy menstrual bleeding. Infertility is also a common finding among PCOS sufferers and the diagnosis is often made during an infertility evaluation.

What causes PCOS?

The genetic contribution to PCOS remains uncertain and there are no environmental causes identified. Insulin resistance, where insulin levels are high may be causative and contribute to symptoms. Obesity may be both a cause as well as a complicating factor with PCOS, further contributing to the signs and symptoms of the disorder. However, there is no known genetic testing available for PCOS and it is unknown whether the condition may itself be inherited.

How is the diagnosis made?

Diagnostic criteria for PCOS have changed many times over past years and there is no universally accepted definition. However, there are consistent physical, laboratory, and ultrasound findings accepted amongst physicians who diagnose and treat women with PCOS.

The following are the most common features and most, but not all must be present for the diagnosis:

• Symptoms: Menstrual irregularity, infertility

• Physical: Elevated blood pressure, High Body Mass Index (BMI >30). Presence of stigmata of high androgen levels: acne, excessive facial hair, hair loss, darkening at nape of neck and armpits

• Laboratory: High levels of male sex hormones (androgens), high insulin levels, high glucose levels, high cholesterol

• Ultrasound: Polycystic ovaries (meaning presence of 12 or more follicles seen in one or both ovaries, thickened uterine lining)

PCOS poses an increased risk of cardiovascular disease. Women with the condition are at increased risk for complications in pregnancy, including miscarriage, gestational diabetes and high blood pressure. Additionally, women with PCOS have a significantly increased risk of long-term diabetes, metabolic syndrome, high cholesterol, and heart disease. Women with long-term untreated PCOS also have an increased risk of uterine cancer, if menstrual symptoms are not treated. Of note, mood disturbances and depression are more prevalent among women with PCOS.

Treatment Options

Obesity contributes substantially to reproductive and metabolic abnormalities in women with PCOS. Multiple studies have demonstrated that weight loss improves many of the signs and symptoms associated with the condition. Weight reduction has proven to improve pregnancy rates, decrease the growth of facial hair, and improve glucose and cholesterol levels. These beneficial changes have been shown in women with weight loss as little as 5 percent.

Without doubt, the most important and successful treatment for women with PCOS is weight reduction.

Women with PCOS should be screened for cardiovascular disease frequently with fasting laboratory testing. Regular exercise, proper diet and weight control are proven methods to reduce cardiovascular disease in young women.

In women with menstrual symptoms ranging from not getting a period to heavy irregular periods, there are several treatment options. Low-dose, oral contraceptives are most frequently used to regulate the menstrual cycle and additionally protect the uterine lining from overgrowth and long term risk of uterine cancer.

Progesterone, given either as injection, orally, or included within an IUD, called the Mirena IUD, also may help regulate menstrual symptoms.

Drugs initially developed to treat type-2 diabetes also are used to treat PCOS. One such drug most commonly used is metformin, also called glucophage. Treatment with this medication helps regulate periods, contribute to weight loss, improve insulin resistance, increase ovulation, and thus, improve pregnancy rate, and help decrease or eliminate the signs and symptoms associated with PCOS.

Conclusions

PCOS remains a common condition among reproductive-aged women and accounts for a myriad of symptoms and physical signs that has potentially serious long-term ramifications. The symptoms of PCOS are commonly associated with other disorders and making the diagnosis is crucial to assure proper treatment. Besides menstrual related disorders and infertility, cardiovascular disease is a largely under-recognized and underappreciated co-morbidity associated with PCOS and must be diagnosed and treated. Treatment of the cardiovascular risk factors, including insulin resistance, hypertension, obesity and high cholesterol, should be incorporated into the routine PCOS patient treatment plan. The gynecologist is only one member of the health care team required to help care for women with this malady.

LINK: www.acog.org/publications/patient_education/bp121.cfm