Polycystic Ovarian Syndrome (PCOS)
Polycystic ovary disease (PCOD) was first reported in 1935 by two gynecological physicians in Chicago, Drs. Stein and Leventhal, who noticed women with irregular cycles and facial hair had small fluid filled sacs in both ovaries, therefore coined the name polycystic ovarian syndrome.
Over time, and with the advent of new technologies, other defining abnormalities have been attributed to this disorder making the term polycystic ovary syndrome (PCOS) more accurate description. Women with this diagnosis have an increase risk for hypertension, cardiovascular disease, stroke, and type 2 diabetes. PCOS, is estimated to affect approximately 10 percent of women, which implies that approximately 3 million reproductive – aged women in the United States have PCOS.
Despite increasing recognition this condition is among the most underdiagnosed syndromes and the most common cause of infertility in this population. One major problem is the definition of PCOS is still being debated among the leading researchers in this field.
At the PCOS Consensus Conference in 2003, the National Institutes of Health – National Institute of Child Health and Human Development (NIH-NICHHD) expanded on the clinical definition of PCOS.
To be diagnosed with PCOS a women needs 2 of the following: multiple cystic areas on the ovaries by ultrasound, hyperandrogenism (elevated testosterone and androstenedione), and / or long term absence of ovulation in women that was not the result of a specific underlying disease of the pituitary or adrenal glands.
Clinically, women present with concerns regarding irregular menstrual cycles, hirsutism, or obesity. However, affected women may complain of profuse heavy vaginal bleeding without hirsutism and may be of normal weight.
By ultrasound the ovaries are increased in size due to enlargement of the cells that produce androgens (stroma cells). Around the periphery of the ovary multiple small, < 10mm, follicles are seen secondary to the hormonal imbalance that prevents the follicles from maturing normally.
Not all women with polycystic appearing ovaries have the complete syndrome. Approximately 20 percent of all reproductive aged women have multiple cystic areas on their ovaries but do not have PCOS. Therefore, polycystic ovaries are not a decisive criteria to diagnose PCOS, but it is a combination of laboratory, clinical, and ultrasound findings.
- Chronic anovulation
- Clinical signs of androgen excess
- Menstrual Irregularities
- Polycystic Ovaries
- > 8 follicular cysts < 10 mm in diameter
- Exclude other causes for elevated androgens
The diagnosis of PCOS is made by ruling out other causes for your symptoms. After reviewing your medical history and performing a physical exam, your physician will determine which tests are necessary.
If you have irregular or absent menstrual periods, the first concern is pregnancy. A pregnancy test would be ordered with the initial blood tests. Your height and weight will be noted along with any increase facial or body hair, loss of scalp hair, acne and acanthosis nigricans, which is a discoloration of the skin under the arms, nape of the neck, under the breasts and in the groin area.
Laboratory testing is needed to make sure you do not have other conditions such as Cushing’s disease / syndrome (overproduction of a male hormone called androgens), thyroid problems, congenital adrenal hyperplasia or increased prolactin production by the pituitary gland.
Initial hormone testing includes TSH, prolactin, 17-hydroxyprogesterone, DHEAS, and testosterone. Based on these results would determine if further provocative testing is warranted. Elevated androgen levels (male hormones) such as androstenedione, DHEAS or testosterone can confirm the diagnosis of PCOS.
Hormones from the pituitary gland Lutinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) are disproportionate. The LH to FSH ratio is usually greater than 2:1, which causes menstrual irregularities and elevated androgens.
These values are not absolute because 30 percent of normally ovulating women have this finding. Therefore, we use this information along with the other test results to confirm this diagnosis.
Insulin Resistance with PCOS
Insulin resistance is defined as the decreased ability of insulin to stimulate glucose transport into the target tissue. This is seen in approximately 50 percent of women diagnosied with PCOS. Of these approximately 40 percent of women will demonstrate some degree of diabetes mellitus by the third or fourth decade of life.
Therefore it is imperative to screen all women suspected to have PCOS for insulin resistance and diabetes mellitus. A fasting glucose to insulin ratio of less than 4.5 is predictive of insulin resistance.
Some women may have a normal ratio but produce higher levels of insulin to keep glucose levels in the normal range. Therefore, in those with high insulin levels a two hour glucose tolerance test is more sensitive in detecting impairment.
We do not fully understand why women develop PCOS. There are women who demonstrate polycystic appearing ovaries on ultrasound but have regular menstrual cycles and no signs of excess androgens while other women develop the entire syndrome associated with PCOS.
One major biochemical feature of polycystic ovary syndrome is insulin resistance which causes a compensatory hyperinsulinemia (elevated fasting blood insulin levels) state. There is increasing data that hyperinsulinemia produces the hyperandrogenism of polycystic ovary syndrome by increasing ovarian androgen production, particularly testosterone and androstenedione and by decreasing the serum sex hormone binding globulin concentration from the liver.
The high levels of androgenic hormones interfere with the pituitary ovarian axis, leading to increased LH levels, anovulation, amenorrhea, and infertility. Hyperinsulinemia has also been associated high blood pressure and increased clot formation and appears to be a major risk factor for the development of heart disease, stroke and type II diabetes.
Obesity is known to be a risk factor for type II diabetes mellitus but is also a common characteristic of women with PCOS. Obesity has been reported in 35 percent to 80 percent of women with PCOS. Truncal obesity, identified by a high waist to height ratio, or a body mass index greater than 26, have a higher free androgen levels and higher degree of insulin resistance.
Recent studies suggest a genetic basis for PCOS. Prevalence of PCOS these cases occur within families of affected women. These genetic abnormalities cause alterations in pathways involved in hormone production and steroid actions in the body.
In addition, the high prevalence of insulin resistance and abnormalities in insulin secretion suggests the gene for insulin and/or its receptor may be involved.
PCOS Treatment Goals
Treatment should be tailored for the individual women’s needs. The therapeutic goals include:
- Reversing the symptoms of androgen excess and hirsutism.
- Establish cyclic menstruation.
- Addressing the metabolic problems such as insulin resistance with weight loss, exercise and medication.