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Polycystic Ovary Syndrome
In PCOS, the follicle never reaches a size big enough to ovulate so the ovary doesn’t produce progesterone and the uterus has no signal to tell it whether to bleed or not, causing infrequent menstruation. Eventually the lining may grow so thick, waiting for the progesterone, that it becomes unstable and sloughs off in an erratic way causing unpredictable bleeding every day or quite heavy bleeding. If progesterone is absent for many months, the lining sometimes gets so thick from the “unopposed” estrogen that the cells can become abnormal, precancerous or even cancerous. Since the follicles never rupture, month after month they fill up in the ovary and create a line of small cysts right near the surface of the ovary, giving the classic “polycystic” appearance. The term “polycystic” means “many cysts” of the ovary, but these are not so much cysts as they are immature, un-ruptured follicles. They are not harmful or cancerous cysts.
The polycystic ovary makes more testosterone than usual, which makes it even harder for the ovary to ovulate. Insulin is the hormone that allows the body to take sugar (glucose) from the bloodstream and move it into the cells to use for energy. Many women with PCOS are relatively resistant to their own body’s insulin, which means they have to make more insulin to get the glucose into their cells for energy. This problem is called insulin resistance. The resulting high levels of insulin cause the ovary to make more testosterone than usual. Testosterone tends to inhibit ovulation. High testosterone levels lead to excess facial hair and acne, thinning or loss of hair from the scalp, and abnormally high cholesterol levels. Excess insulin also promotes the storage of fat, making it hard to lose weight. Women with PCOS, particularly those who are overweight, are at an increased risk of diabetes. Other health problems can also occur such as high blood pressure, abnormal cholesterol levels and heart disease.
A woman with PCOS is not necessarily going to exhibit all of the aspects of the syndrome. Some may be lean and others may not have any unwanted hair growth. The treatment for a woman with PCOS is directed toward alleviating her particular symptoms and limiting their risk for developing cancer of the uterus. Lifestyle changes and treatments to prevent diseases associated with PCOS can also be implemented. The most common treatment for irregular periods is the birth control pill. The “pill” provides both estrogen and progesterone to regulate the menstrual periods and to protect the lining of the uterus from getting too thick. This effect allows for lighter periods and a reduced risk of cancerous changes to the lining. Another hormonal option is to give progesterone alone for 10-12 days each month, though this option doesn’t prevent unintended pregnancies.
Excess hair growth is a frustrating problem and is due to the effects of excess testosterone on the hair follicles. Normally the hair follicles on a woman’s face and lower abdomen don’t make thick hairs, but with excess testosterone they do. The hair follicles may also make excess sebum leading to acne. One effective treatment is the birth control pill, which lowers testosterone levels so as to slow the formation of new thick hair follicles and lessen acne. It takes several months to see the improvement. Other medicines that block testosterone production such as spironolactone (Aldactone), flutamide (Eulexin) and finasteride (Proscar) can be given but must be accompanied by birth control because they can cause birth defects, particularly in male fetuses. A prescription facial cream called Vaniqa is also available to help slow facial hair growth without altering hormones. Electrolysis and laser hair removal can also be used to temporarily remove the hair, once the testosterone levels are suppressed.
It is estimated that up to 3/4 of patients with PCOS have some form of insulin resistance, particularly those who are overweight or obese. Up to 15% of patients actually have diabetes. Studies have shown that weight loss can improve or eliminate these problems, but many patients also need the help of medications to lower insulin levels and balance their sugar metabolism. Medications include metformin (Glucophage), Avandia and Actos.
Some of these medications must be monitored carefully to limit side effects and to ensure proper dosing. They also sometimes allow the ovaries to start functioning normally, which could result in more regular menstrual cycles, ovulation and pregnancy.
Infertility problems occur with PCOS because of the lack of ovulation. The most common treatment for inducing ovulation is to give the fertility pill clomiphene citrate (Clomid, Serophene). Clomiphene helps the body make more follicle-stimulating hormone (FSH) to stimulate the growth and release of follicles and their eggs. Eighty percent of patients will ovulate and half of those who ovulate will ultimately conceive within several attempts. There is a modest increase in the risk of having twins (7%) with clomiphene. Some patients do not respond to clompihene and may require other therapies. One option is metformin to help the ovaries ovulate, or to respond better to other fertility medications. Another option is to use daily fertility shots that contain FSH. These shots directly stimulate the ovaries, but must be used with care because patients with PCOS can have an excessive response to these medicines and make too many eggs, increasing the risk of multiple pregnancies including the possibility of triplets or higher order pregnancies. Therefore, these medicines must be monitored carefully by a trained Fertility Specialist (Reproductive Endocrinologist). Some patients will benefit from in Vitro Fertilization (IVF), where eggs are removed from the ovaries after stimulation with fertility shots, then mixed with sperm in a dish in a laboratory to create embryos. A limited number of embyos, one or two, can be replaced back into the uterus. This lessens the risk of high-order multiple gestation compared to using the daily fertility shots without IVF. Any remaining embryos can be frozen, if desired, for use in future fertility attempts.
In summary, there are effective treatments for the various symptoms of this common syndrome called PCOS.