Polycystic Ovarian Syndrome (PCOS) is the most common form of ovulation disorder in the developed world. In the last 10 years, our understanding of the cause of PCOS has advanced so much that more is known about PCOS than ever before. Consequently, there are more treatment options available now than ever before. But it is hard to diagnose.

Diagnosing PCOS

To be diagnosed with PCOS, you must meet two of three key criteria:

1. Infrequent periods (anywhere from 35 days apart to total lack of periods).


2. Evidence of elevated androgen (male hormone) reflected in physical signs like facial hair growth or laboratory tests that show elevated levels in the blood.


3. Ovarian appearance shown by ultrasound tests. The name “polycystic ovary” is actually something of a misnomer since the ovaries do not really contain ‘cysts’ but, rather, many antral follicles. Technically, antral follicles are cystic (fluid filled), so the syndrome came to be called ‘polycystic ovary’ syndrome. The typical PCOS ovary has 10 to 30 antral follicles arrayed around the outer edge of the ovary, giving it a “pearl necklace” appearance on ultrasound. The central portion of the ovary tends to be dense and devoid of follicles.


4. There are other symptoms that play ‘supporting roles,’ such as:
   • Elevated ratio of luteinizing hormone (LH, a hormone produced by the pituitary gland that triggers ovulation) to FSH (follicle-stimulating hormone, which stimulates the recruitment and growth of immature ovarian follicles in the ovary).
   • Obesity
   • In fertility

Challenges of diagnosing PCOS

In fact, there is a broad spectrum of manifestations of PCOS, so it can be difficult to diagnose. For example, the ‘typical’ PCOS patient is obese, hirsute, and doesn’t menstruate. But, only about two thirds of patients with PCOS are obese. And not all have excess facial hair growth or absent periods. Some women with PCOS conceive spontaneously even if they have infrequent periods.

So, most patients with PCOS are not ‘typical’ at all. The wide range of signs and symptoms made it confusing for researchers to ‘define’ PCOS. (It was not until 2004 that these criteria were developed by the European Society for Human Reproduction/ Embryology and the American Society of Reproductive Medicine.)

Causes of PCOS

Inherited insulin resistance is the underlying disorder that causes PCOS. The relative insensitivity of one’s cells to insulin means that, in order to maintain a normal blood sugar level, circulating insulin levels must be higher than normal.

High levels of insulin lead to other problems including increased androgen production in the ovary, menstrual disorders and infertility. Insulin resistance causes abnormal fat metabolism which increases the risk of obesity. In turn, obesity increases insulin resistance leading to a ‘vicious circle’ of weight gain and ovulation dysfunction.

Treatment for PCOS

Because it is an inherited condition, there is no ‘cure’ for PCOS, but there are a variety of methods to treat its symptoms:

1. Weight reduction. Though difficult to accomplish and maintain, weight reduction may have a greater impact than any other treatment approach. A loss of as little as 10 percent of body weight can improve ovarian function. Unfortunately, insulin resistance often makes it easier to gain weight and harder to lose it. A combination of diet and exercise is the preferred approach to weight loss, but more extreme measures such as gastric banding may be required.


2. Medication for insulin resistance. The most common medical treatment for insulin resistance is metformin, a medication designed for the treatment of Type II diabetes mellitus. While most people with PCOS are not diabetic, metformin helps them by improving their insulin sensitivity, thus reducing the amount of circulating insulin. Over time, this steadily improves ovarian function, though it rarely restores normal ovulatory cycles. Metformin is usually used in conjunction with ovulation-inducing drugs like clomiphene. Some patients find that metformin makes it easier to lose weight through diet and exercise.
   • Note: metformin can have some side effects, most notably diarrhea and nausea. These can usually be avoided by working up to the final dose very slowly. But, if the side effects just can’t be tolerated, there are alternatives to metformin including rosiglitazone (Avandia®) and pioglitazone (Actos®).
   
   
3. Treatment of hirsutism.
   • If you are not trying to conceive, hirsutism is best treated with a hormonal contraceptive to suppress androgen production by the ovary. This can be supplemented with a medication called spironolactone, which blocks the effect of androgens on the hair follicles. But, neither should be taken if trying to conceive.
   • If you are trying to conceive, there is a topical cream, Vaniqa, that may be helpful.
   
   
4. Ovulation induction. If you are trying to conceive and weight loss alone has not restored normal ovulatory function, treatment with ovulation-inducing medication is recommended. Clomiphene citrate or Clomid® is most commonly used. Sometimes letrozole or Femara® is used, though it was designed for the treatment of estrogen-sensitive cancers and it has not yet been endorsed by the FDA for use as an ovulation-inducing agent. However, many studies show it to be safe for this use. If Clomid® or Femara® are unsuccessful at stimulating follicle maturation, the addition of metformin may make all the difference.

If you think you may have PCOS, it may be helpful to seek advice from Dr. Janet Kennedy, a reproductive endocrinologist at NCRS who has a special interest in PCOS.