Polycystic Ovary Syndrome (PCOS) affects millions of women in the U.S. It is estimated that between 5-10% of women suffer from PCOS, making it the most common hormone disorder that exists in women of childbearing age. PCOS is often diagnosed early in a woman’s life, during the transition into puberty, or it may only apparent when a woman is trying to get pregnant but finds she has difficulty conceiving.
The symptoms of PCOS are well-known, and all arise from the fact that levels of the reproductive hormones in the PCOS patient are altered. Women may experience a range of symptoms, including irregular or missed periods, heavy periods, difficulty becoming pregnant, excess or male-pattern hair growth, weight gain, acne, and cysts on the ovaries.
The appearance of many small "cyst-like" follicles on the ovaries on ultrasound gives the condition its name. Many women experience a combination of several symptoms, and the pattern of symptoms can vary greatly from woman to woman. Over the years, experts have evaluated and reevaluated how to define and diagnose the condition.
Because there are many other disorders involving the sex hormones, distinguishing between PCOS and other related conditions can sometimes be tricky, particularly since some conditions have overlapping symptoms. For this reason, it is important to visit your doctor if you believe you may have PCOS or another hormone disorder, so a specific diagnosis can be made.
PCOS may also be due to too much insulin circulating in the body: insulin is the hormone that helps sugar gain entry into the body’s cells from the blood stream. Indeed PCOS has many similarities to insulin-related health issues like insulin resistance, metabolic syndrome, and diabetes.
Because PCOS affects so many women, it is a condition of which all women should be aware. One reason for this is that it is important to be diagnosed and treated for the syndrome if you suffer from it, in order to minimize symptoms and any complications that might arise. It is important to manage PCOS because it can put women at higher risk for other conditions, like high cholesterol, high blood pressure, heart disease, and diabetes.
There are many effective treatment options available these days — from lifestyle changes to hormone therapies to blood sugar medications. We will outline the symptoms, causes, and treatments for PCOS, including information about being or becoming pregnant if you already have PCOS. Though research continues to be done, we know a lot more about the condition than we did even a decade ago, and the development of more effective treatments has led to vast improvements in quality of life for many PCOS patients.
Women who suffer from PCOS can have very different experiences, and may initially visit their doctors with various constellations of symptoms. Many women develop PCOS around the time of puberty, or even prior to it, as the hormone environment in the body is dramatically shifting. But for others it doesn’t become apparent until later in life, often after years of suffering from irregular periods or after they find they are having difficulty getting pregnant. Sometimes, it develops after a large weight gain, perhaps triggered by the change in hormone levels that may follow an increase in body fat. To be diagnosed with PCOS, a woman must experience two of the following three symptoms:
- Menstrual Irregularity. Many women who are diagnosed with PCOS have irregular or missed periods, often with 35 days or more between periods. Menstrual irregularity is a common symptom of PCOS.
- Excess Androgen. PCOS patients have too much androgen ("male" hormones) circulating in their bodies. This is responsible for male-pattern hair growth, often on the face, back, chest, or stomach. Acne, or other skin problems, is another common symptom of PCOS, which may develop as a result of excess androgen.
- Polycystic ovaries: The ovaries may develop small but numerous "cyst-like" follicles, which doctors can spot with an ultrasound. However, at least one of the other two symptoms should also be present, because it is possible to have cystic ovaries without actually having PCOS.
Many girls who go through early or premature adrenarche (PA) do go on to develop PCOS: some studies have estimated that 10-20% of girls with PA will develop PCOS. (Because there are also other causes for PA, girls who experience it should visit their doctors.) Acne and weight gain, despite attempts to lose weight and exercise, may also develop in adolescence, along with irregular periods. As for adults, hormone, insulin, and blood glucose tests may reveal that a teenage patient is suffering from PCOS, when all other possibilities have been ruled out.
Often, being born at a low birth weight can put a girl at higher risk for PCOS and for developing other metabolic problems later in life. As mentioned earlier, though the evidence is a little mixed, having a mother or sister with PCOS appears to put a girl at a 5-times higher risk of having PCOS herself. Just having a family member with PCOS can also put a young woman at a higher risk of developing other hormone and metabolic problems.
Since PCOS affects the sex hormones and reproductive health, it can make becoming pregnant difficult; it may also increase one’s risk during pregnancy. Since PCOS also affects insulin levels and metabolic health, having the condition can put a woman at greater odds for developing complications like type 2 diabetes, obesity, heart disease, high blood pressure, and high cholesterol and blood fats (triglycerides). Women who ovulate at least some of the time may have lower risk for developing these conditions than women who never ovulate. For all women with PCOS, it is very important to work with one’s doctor to manage it well, in order to minimize the risk for developing one or more of these related conditions.
Most PCOS patients with insulin resistance have increased insulin production, leading to too much insulin circulating in the blood. This creates a vicious cycle, in which insulin actually stimulates the production of testosterone from the ovaries, which suppresses ovulation. Higher levels of testosterone also lead to the darkening of the skin in certain areas, skin tags, fatty liver disease (non-alcohol related), and sleep apnea.
But most importantly, the insulin resistance that can occur with PCOS puts a woman at a much higher risk of developing type 2 diabetes. This happens when the body does not produce enough insulin to compensate for the insulin resistance that can develop with PCOS. Women with a family history of PCOS are much more likely to develop type 2 diabetes. The risk of developing type 2 diabetes for PCOS patients in general is about 10%, which is considerably higher than healthy women of the same age, whose risk is only about 3%. One’s doctor will determine the best way to screen for type 2 diabetes, and possibly repeat testing every couple of years to keep a close eye on the situation.
Over the long-term, the diabetes drug metformin may also increase ovulation by reducing insulin levels. However, at least six months of metformin may be needed to have an effect on ovulation. For this reason, clomphene citrate is generally the first choice among doctors, although a combination of metformin and clonphene citrate may be favored under certain circumstances. Metformin, combined with diet and exercise, may be used if the need for conception is less urgent, and has the advantage of being associated with a lower rate of multiple births.
Injections of hormones called gonadotropins may also be used to increase fertility. These help egg mature and stimulate ovulation. Laparoscopic ovarian surgery may also be used to destroy ovarian cells that produce excess androgen. Both methods are considered second-line treatments if clomiphene (or combined clomiphene/metformin) are unable to induce ovulation.
in vitro fertilization, or IVF (in which the egg and sperm are placed together in a laboratory dish to be fertilized), is usually considered a third-line treatment; but it can be an earlier option for certain couples, so it is important to talk to your doctor about which options are appropriate for your situation.
There is also the risk of having multiple births with medical therapies for infertility, including IVF. Unlike medical therapies which allow the sperm and eggs to fertilize in your body, however, IVF might be a reasonable option for some PCOS women who fail clomiphene therapy because the sperm and eggs are fertilized in a dish and only one embryo can be transferred into your uterus.
Statins may also be prescribed for some women who need extra help managing cholesterol levels. Depending on the severity of your symptoms, your doctor will determine the best management plan for you. Taking part in the lifestyle changes (caloric restriction – diet – and exercise) that have been shown to help manage PCOS symptoms and treating any other PCOS-related health issues will be the best way to improve your health and reduce your risk for complications over the long term.
PCOS is the most common hormone disorder in women in the U.S. Typical symptoms include irregular or absent menstrual cycles, male-like hair growth, acne, and ovaries with multiple cysts visible on ultrasound. Looking at the patient’s history, symptoms, and blood work, a doctor can rule out other hormone disorders that share symptoms with PCOS.
Most PCOS patients have insulin resistance (disproportionate to their body weight), and several of the risk factors associated with cardiovascular disease, including high cholesterol/blood fat levels, abdominal obesity, high blood pressure, and glucose intolerance, insulin resistance, or type 2 diabetes. A subset of PCOS patients also experience infertility due to hormone imbalances. Fertility treatments like IVF may help PCOS patients become pregnant if they wish to start a family, although they may not be effective in all patients. Once pregnant, it is certainly possible for a PCOS patient to carry a fetus to term, though there are certain risks involved.
Researchers are still working to understand the underlying causes for PCOS, and to develop effective treatments to manage both the metabolic and the reproductive symptoms associated with PCOS. Working closely with one’s doctor to determine the best management plan, which can include lifestyle changes, hormone therapies, and diabetes medications, is the best way to improve one’s quality of life and reduce odds of developing complications down the road.