Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is a hormonal disorder that prevents the eggs in the ovaries from maturing properly, often creating numerous fluid-filled sacs known as ovarian follicles. This often causes irregular menstrual cycles and infertility.
PCOS is characterized by excess levels of androgens (the hormone testosterone) and higher than average insulin levels. Though androgens naturally occur in women, women with PCOS have higher levels of androgens than those typically found in females. Elevated levels of testosterone contribute to the changes seen in how the ovaries function.
Commonly experienced symptoms of this hormone imbalance include male-pattern hair growth (upper lip, chin, face, chest and abdomen), acne and abnormal uterine bleeding. Women with PCOS also have an increased risk for hypertension, cardiovascular disease, stroke and type 2 diabetes.
There is no cure for PCOS, but medical treatments and lifestyle changes can reduce testosterone levels and help patients effectively manage symptoms.
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Causes of PCOS
Doctors do not fully understand why women develop PCOS. Some women’s ovaries appear to be polycystic or enlarged on ultrasounds, even though the patient has regular menstrual cycles and no signs of excess androgens. But other women develop a number of characteristics associated with this condition.
One major feature of polycystic ovary syndrome is insulin resistance, a situation in which the hormone that regulates fat and carbohydrate metabolism is blocked from entering cells. There is increasing evidence that insulin resistance causes the body to increase the production of insulin and androgens like testosterone.
The high levels of androgenic hormones change the signals the pituitary gland sends to the ovaries, leading to increased luteinizing hormone (LH) levels, irregular or absent ovulation and menstruation, and infertility. Higher levels of insulin are also associated with high blood pressure and increased clot formation. PCOS also appears to be a major risk factor for the development of heart disease, stroke and type 2 diabetes.
PCOS cases often occur in women whose immediate family members also have the condition. Recent studies suggest that PCOS is likely hereditary and that genetic abnormalities have changed the pathways involved in hormone production within the body.
In addition, the high prevalence of insulin resistance and abnormalities in insulin secretion suggests the gene for insulin or its receptor may be involved.
PCOS is often identified using three common symptoms: irregular or absent periods, excess androgens (elevated testosterone and androstenedione levels), and multiple cystic areas on the ovaries.
Other seemingly unrelated PCOS symptoms that patients might experience include:
- Irregular ovulation, or absence of ovulation (anovulation).
- Weight gain and difficulty managing weight.
- Low energy and fatigue.
- Insomnia and difficulty sleeping.
- Pelvic pain.
- Excessively heavy menstrual bleeding.
- Discoloration of the skin under the arms or breasts, on the nape of the neck, or in the groin area (known as acanthosis nigricans).
- Excess hair growth on the face, arms, back, hands, feet and chest (known as hirsutism).
- Male pattern baldness (known as virilization).
- Ovaries that appear to be swollen or enlarged.
- Polycystic ovaries.
- 8 or more follicular cysts less than 10 mm in diameter.
Ovarian cysts alone do not always mean the patient has PCOS. Approximately 20 percent of all reproductive-aged women have multiple cystic areas on their ovaries but do not have PCOS.
PCOS symptoms vary greatly from person to person, so a combination of laboratory, clinical and ultrasound findings are often needed to confirm the diagnosis. The process begins by ruling out other potential causes of the patient’s symptoms.
A physician will review a patient’s medical history and perform a physical exam, after which he or she will determine which tests might be necessary. If the patient has irregular or absent menstrual periods, the provider will start with a pregnancy test and order initial blood tests to rule out potential pregnancy.
Initial hormone testing will analyze the blood for elevated androgen levels, such as androstenedione, dehydroepiandrosterone sulfate (DHEAS) and testosterone. The physician will also perform laboratory testing to rule out other conditions such as Cushing’s syndrome (hypercortisolism), thyroid problems, congenital adrenal hyperplasia or increased prolactin production by the pituitary gland.
Treatments plans for PCOS can focus on reversing the symptoms of the disorder or restoring ovulation to help the patient become pregnant. A physician may also recommend weight loss or exercise to manage symptoms.
The PCOS specialist may address a patient’s needs by prescribing medications such as birth control to slow the production of androgens, or insulin-sensitizing medications to stabilize blood sugar levels. Approximately 50% of women with PCOS experience insulin resistance. Approximately 40% of women who had PCOS-related insulin resistance were diagnosed with a form of diabetes between the ages of 30 and 40, so it is important that women who have this symptom be screened for diabetes.