Polycystic Ovary Syndrome
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Polycystic Ovary Syndrome (PCOS) is the commonest hormonal abnormality in women, and is a result of the ovary not working properly. It is linked with abnormal periods, obesity and high levels of male hormones. Despite modern tests such as scans and blood tests it can still be difficult to diagnose.
To confirm someone has PCOS, they must have two out of three of the following things:
An ovary that is large or that contains many small cysts (12 or more measuring 2 - 9mm)
Symptoms or blood test evidence of raised levels of male hormones (such as spots, some hair growth and other hair loss)
Irregular or no periods
Each ovary contains millions of eggs and each month one should grow and then be released at the right time (ovulation). In women with PCOS this process becomes disturbed. As a result of this disturbance the ovaries contain many small cysts that are no bigger than 1 cm.
When lots of small, fluid filled cysts are seen in the ovaries on scan without any other symptoms, the women is simply said to have polycystic ovaries. This occurs in about 1 in 5 women in the UK. These are not the same as other ovarian cysts. (link to follow)
In PCOS, the cysts may be accompanied by an imbalance of sex hormones, in particular the male hormones known as androgens. Testosterone is the best-known androgen. Normally women have both oestrogens (female hormones) and androgens (male hormones). In PCOS the balance is tilted towards overproduction of androgens. This can cause acne and / or excessive hair growth on the face and body. It can also cause hair loss from the head – alopaecia. Blood tests may show a raised level of testosterone. As well as higher levels of male hormones there may also be higher levels of some female hormones that control the way the ovaries work - luteinising hormone (LH) and follicle stimulating hormone (FSH).
PCOS is also associated with irregular or few periods, and sometimes no periods at all. If the periods are irregular, it is likely that ovulation is not occurring. As a result, women may experience problems getting pregnant.
Women with PCOS may have difficulty controlling their weight. They are often overweight and this makes the symptoms even worse. Although sometimes difficult to achieve, weight loss can lead to a dramatic improvement in symptoms.
The hormone insulin (which helps to control the level of sugar in the blood) is found at higher levels in the blood of women with PCOS. Insulin increases the production of androgens in the ovary, which in turn seems to affect the way the normal ovary works. Higher levels of insulin would normally cause a drop in the sugar levels in the blood, but in PCOS the sugar levels are normal despite the higher levels of insulin. This is called insulin resistance and is linked to a greater chance of developing diabetes.
Women with PCOS may also have an increased chance of getting high blood pressure and heart disease. Finally, if there are very long gaps between periods, there is small increase in the risk of cancer of the lining of the womb. Your specialist will also assess your risk of these conditions and arrange investigations if they are needed.
Why does it occur?
PCOS is common affecting between 5-10% of women of childbearing age. It is thought that there may be a genetic reason why some women develop PCOS. Women with PCOS often describe female family members with similar symptoms. The males in the family often have frontal baldness. This is thought to be the male version of the syndrome.
Investigations
A specialist will suspect that you may have PCOS from your symptoms and an examination. To confirm this diagnosis:
- A scan will be done to look at the ovaries
- A blood test can check the level of testosterone. The female hormones luteinising hormone (LH) and follicle stimulating hormone (FSH) may also be measured. These are best checked in the first 3 days after a period starts
- Unwanted hair (hirsuitism) can be graded using the Ferriman/Gallwey score system
These tests can also be done to rule out some other serious but less common, conditions that have similar symptoms.
Treatment options
Weight loss
Women with PCOS who are overweight or obese are advised to lose weight. Ideally body mass index (BMI) should be between 20 and 25 (BMI = W ÷ H², where W is weight in kilograms and H is height in meters). Symptoms improve dramatically and may even disappear with weight loss. Weight loss will reduce insulin levels and so correct the hormonal imbalance. This may be the only treatment needed to restore ovulation or improve symptoms.
The best diet for women with PCOS, is one which promotes more stable levels of blood sugar and lower levels of insulin. The standard low fat, high carbohydrate weight loss diet is not the best approach for women with PCOS. High intakes of carbohydrates, especially refined carbohydrates (i.e. sweets, white bread, white rice, etc.) will quickly turn to sugar and cause high levels of insulin. Since high levels of insulin can cause many problems for women with PCOS, a better diet is a low glycaemic index diet. This is a diet that includes foods or combinations of foods that will not cause a rapid rise in blood sugar. The low glycaemic carbohydrates tend to have more fibre than the higher glycaemic foods. For example, bran cereal (10 gm fibre /1/2 cup) has a lower glycaemic index than cornflakes (1 gm fibre/1/2 cup). Low glycaemic foods usually contain unprocessed grains and cereals.
Carbohydrates should be spaced throughout the day to avoid peaks in blood sugar and insulin production. Carbohydrates should also be mixed with a protein and / or fat, rather than be eaten alone. It is also best to avoid those carbohydrates that trigger more hunger or cravings. Pasta can cause this phenomenon in some people.
In extreme obesity, drugs may be used to aid weight loss. These act by either reducing the absorption of fats (orlistat) or by suppressing appetite in the brain (sibutramine). Metformin is another drug that is often used to treat PCOS. It can help weight loss and may help to regulate periods and bring hormone levels back to normal.
First line treatments
The combined oral contraceptive pill “the pill” (COC) regulates periods and reduces the risk of cancer of the womb lining. The COC pill also increases the levels of sex hormone binding globulin (SHBG) in the blood, this is something that testosterone sticks to in the bloodstream. The higher level of SHBG will ‘mop’ up some of the extra androgens, reducing the symptoms of acne and unwanted excessive hair.
Dianette is a slightly different pill that can be prescribed to treat acne or hirsuitism and also has a contraceptive effect; however, it may also increase the risk of deep vein thrombosis (blood clot). For this reason it should only be used for a short time. Long term treatment may be considered if the risks and benefits to an individual are assessed. Yasmin is another COC that may have many benefits.
Second line treatments
If the combined oral contraceptive pill or Dianette are not suitable the anti-diabetic drug metformin, is a good alternative. It increases the sensitivity of the tissues to insulin, reduces insulin levels in the blood and so reduces excess androgen levels. It may therefore restore ovulation and regular periods. It may also improve acne and hirsutism.
Other drug treatments
The drug spiranolactone, normally used to increase water output from the kidneys can also work against male hormones. It is useful in women unable to take the COC or metformin. Side effects may include gastric disturbance and frequent periods.
Finesteride is a powerful drug usually used to treat male-pattern baldness and overgrowth of the prostate gland in men. Although the manufacturer does not license it for use in PCOS, it is widely used in specialist clinics. It is particularly useful in resistant cases with good results and has few side effects.
Topical preparations
Eflornithine HCl cream (vaniqa) is a new approach to helping women with increased facial hair. It works directly to slow hair growth. Vaniqa does not remove hair, so it needs to be used together with a hair removal method. The studies so far have looked at facial and neck hair only, so vaniqa is not recommended for use elsewhere on the body.
Surgery
Part of the tissue of an ovary can be destroyed using keyhole surgery – laparoscopic ovarian drilling. This is especially good if fertility is a problem, but it may also have some long term health benefits.
Fertility
Women with PCOS often have difficulty conceiving. This is a subject covered by our leaflet SMS patient information - fertility. (link to be added)
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