Many women have polycystic ovaries (PCO) without having Polycystic Ovarian Syndrome. Approximately 25 percent of women have PCO on ultrasound scan. However, less than half of women with PCO will have the Syndrome (PCOS).

Polycystic Ovaries (PCO)

A polycystic ovary is a larger than normal, with more small cysts or follicles within the ovary than usual. Polycystic ovaries are diagnosed with an ultrasound scan and approximately 25 percent of all women will have polycystic ovaries on a scan, however, they may have no other clinical abnormalities or symptoms.

Polycystic Ovarian Syndrome (PCOS)

Some women with PCO will also have one or more clinical features or symptoms, these combined are known as PCOS. A hormone imbalance is thought to cause these various symptoms. PCOS is usually, but not always, associated with irregular or absent periods and in some women, fertility problems or excessive facial or body hair.

Causes and risk factors

The causes of PCOS are not fully understood, but the symptoms of PCOS are related to abnormalities in hormones that control the menstrual cycle.

Typically these hormonal abnormalities include:
 

• Higher than normal levels of Insulin  
• Higher than normal levels of LH (luteinising hormone), which stimulates ovulation (egg release) and the production of hormones in the ovaries.  
• Reduced levels of FSH (follicle stimulating hormone) and progesterone.  
• Increased levels of Prolactin. This hormone stimulates the body to produce milk in pregnancy and the post natal period.  
• Thyroid levels- hormones produced in the thyroid gland stabilise the metabolisim and in PCOS the levels can be affected.  
• Raised levels of androgens (sometimes called male hormones), particularly testosterone.

Family link- the condition can sometimes run in families. If any relatives (mother, aunts, sisters) are affected with PCOS, the risk of developing PCOS may be greater.

Insulin resistance – Insulin is a hormone produced by the pancreas to regulate the level of glucose (sugar) in the blood. Some women produce more insulin than normal because their body tissue appears to be resistant to its effects. When this happens, the higher levels of insulin also cause increased production of testosterone in the ovaries. This prevents normal ovulation and causes other symptoms associated with PCOS.

Being overweight- Insulin resistance can also lead to being overweight. Excess fat makes the body produce more insulin. Being overweight is a risk factor which can make the symptoms of PCOS worse, leading to the effects described above.

Later in life, women with PCOS are at an increased risk of diabetes, hyper-tension (raised blood pressure) and high cholesterol as a result of raised insulin levels, insulin resistance, obesity and hormone imbalances.

Irregular or absent periods- over many years this increases the chance of Endometrial cancer or cancer of the lining of the womb. However, although the risk is increased, it is still rare and medicines to regulate periods can be used.

Fertility- some women with PCOS can have problems getting pregnant. However, once diagnosed there are many treatments which can be effective. Women with PCO/PCOS may also be more at risk of recurrent miscarriages, see our expert interview for more information.

Symptoms

Most women with PCOS have polycystic ovaries on scan and one or more of the following symptoms, which can vary from mild to severe. They usually occur in teenagers, when menstruation starts, or in the early 20s. However, for some women PCOS only becomes apparent when they are having difficulty trying to conceive.

Symptoms can include:

• Irregular or absent periods
• Excessive hair growth on the body or face
• Weight gain
• Skin problems- acne or oily skin.
• Thinning hair and hair loss
• Depression and mood changes
• Problems getting pregnant or miscarriages

If you are worried about any of these symptoms it is important that you make your doctor aware of your concerns.

Diagnosis

The diagnosis of PCOS is usually based on a woman’s history, symptoms, physical examination, blood tests and ultrasound scan. These are used because women can have different and varying symptoms and therefore one test alone cannot diagnose it.

Other illnesses can also cause some of the symptoms associated with PCOS. Some of these include low thyroid levels (hypothyroid) and problems with the adrenal gland. These can cause higher levels of male hormones that may result in acne or excess hair growth and therefore the doctor will use a number of methods to come to a diagnosis.

Ultrasound- is used to diagnose PCO, this passes sound waves through the body to create a picture of the ovaries. However, because women without PCOS can have ovarian cysts, and because ovarian cysts are usually but not always present in PCOS, ultrasound is not the only test used for diagnosis.

Blood tests- along with an assessment of the symptoms, blood tests will probably be needed. Women with PCOS will normally have raised levels of male hormones (testosterone), as well as raised levels of luteinising hormones (LH), the blood tests will check for these as well as insulin, glucose and cholesterol levels.

When diagnosed with PCOS women should have regular checks to look out for early signs of the associated long term risks. Your doctor will advise which checks are necessary and when to have them.

These checks can include:

Blood pressure (BP)- PCOS can lead to an increased risk of raised BP.

Diabetes checks – women with PCOS have a 20 percent chance of developing diabetes due to associated insulin resistance.

Cholesterol check – PCOS can lead to higher cholesterol, a test may be recommended.

Treatment

There is no cure for PCOS but there are treatments that can help with the symptoms and there are things that women can do to manage their condition.

Lifestyle

One of the most important things is to maintain a healthy lifestyle by eating a balanced diet, having regular meals and taking regular exercise. For some women this may be enough to manage and improve symptoms and no further treatment is needed.

Women with PCOS can often be overweight. Excess fat cells in the body can cause worsening of insulin resistance and the hormonal changes of PCOS. In this situation it is even more important to maintain a healthy life style. Losing weight will reduce the amount of insulin and testosterone that the body produces, this increases the chances of ovulation and therefore improves fertility. It can also reduce excessive hair growth and acne.

If you are suffering from this condition you may find it difficult to lose weight, but you should not feel there is no help. Your GP can refer you to a dietician and a regular exercise programme can be of great benefit.

Other treatment for symptoms of PCOS depends on the woman's stage of life and her symptoms.

Hormone treatment

The contraceptive pill - for younger women who want birth control, the contraceptive pill can regulate periods and help to reduce the risk of endometrial cancer.

Gonadotrophins- are hormones produced in the body which stimulate the ovaries. They can be given to encourage ovulation, but there can be risks of over stimulation.

Medication 

Clomifene - is a medication that can be used to stimulate the ovaries into ovulation (releasing an egg) and help women to get pregnant. 

A diuretic - this type of drug causes the body to lose excess water and certain ones can be useful in lessening the effect of male hormones, such as excess hair or acne.

Fertility treatments

Some women with PCOS may have fertility problems, because of reduced ovulation and when ovulation does happen, the egg that is released may be of poorer quality. This does not affect all women with PCOS and there are treatment options for women that it does affect. Treatments including Clomid, Gonadotrophins, Metformin, surgery and sometimes IVF (in vitro fertilisation) may be needed.

Surgery

Surgery- involves a laproscopic procedure called ovarian diathermy or ‘drilling’. A small camera or telescope is inserted into the abdomen through a very small cut, heat or diathermy is then used to remove some of the ovary. This may correct the hormone imbalance and can re-start ovulation.

Diabetes treatments

Metformin- is a tablet that is used to treat diabetes. It decreases levels of insulin and in women with PCOS this can reduce male hormone levels and may help to improve their fertility.

Other treatments

Excessive hair growth can also be treated at home by normal methods (waxing etc.), or electrolysis and laser treatment may also be used if necessary.

Acne can be helped by taking certain types of the oral contraceptive pill and the GP may recommend other usual treatments for acne such as creams and antibiotics.

Non-medical or alternative therapies

Many providers of alternative healthcare offer help for women with PCOS, but if considering this, it is important to take advice from your GP. Always ensure the practitioner explains the risks and benefits of their proposed treatments and any medication changes should be managed by your GP.

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

PCOS: Text Version

This interview was recorded in June, 2009.
 
Welcome to this month’s Wellbeing of Women podcast. Today we will be discussing Polycystic Ovary Syndrome or PCOS, which affects up to 10-15 percent of women, and is one of the leading causes of fertility problems in women.
It is associated with a range of health problems and may have a significant effect on the quality of life of women of all ages. The condition cuts across many medical specialties and therefore requires a holistic approach to management.
While PCOS cannot be cured, there are a number of ways to reduce the long-term health risks associated with it. Women need relevant and up-to-date information about this condition so that they can make lifestyle changes, access support, and lead healthy and fulfilling lives.

Today I have Raj Rai with me, who is this month’s expert on the topic. He is a consultant gynaecologist, clinical lecturer in Reproductive Medicine at St Mary’s Hospital / Imperial College and a world-leading expert on PCOS and recurrent miscarriage.

[Dr Rai is currently involved in a study funded by WoW, which started in 2007. The study is looking at links between women with polycystic ovaries and a gene variant (PA-1) which is involved with the breakdown of blood clots and the implantation of the embryo. It is hoped that this research could identify new causes for recurrent miscarriage and shed light on links between recurrent miscarriage and abnormalities in blood clotting.]

Hello Raj and thank you for being here today.

What is Polycystic Ovary Syndrome (PCOS)?

The key to answering this question Penny, lies in the word - syndrome. And in this case the word syndrome refers to a collection of clinical features. Now in this country and in Europe, PCOS refers to a spectrum of disorders ranging from women diagnosed with polycystic ovaries diagnosed on a scan with no obvious clinical features, to those who may present with severe hormonal abnormalities, such as irregular or no menstruation, raised levels of androgens. Androgens are the male hormones and this may lead to hirsuitism which is excessive facial or body hair. So I think the key is it is a collection of clinical features together with ultrasound findings of polycystic ovaries.

What is the difference between having polycystic ovaries and PCOS?

There is an important difference Penny, polycystic ovaries are diagnosed with an ultrasound scan and approximately a quarter or 25% of all women will have polycystic ovaries on a scan and these women have no other clinical abnormalities or symptoms. In contrast polycystic ovarian syndrome is the most common reproductive or endocrine condition for women of reproductive age. As you said in your introduction it affects 10-15% of all women of reproductive age and being a syndrome, refers to the association between polycystic ovaries together with clinical features

What are the symptoms of PCOS?

These will differ according to the age of the woman. So if you start early in ones life, polycystic ovarian syndrome first manifests itself or becomes apparent around the time of adolescence; when a young girl presents with menstruation or menarche starting a little later than other girls in class, or indeed she may not menstruate at all. Moving a little later in life it’s common to find irregular menstruation cycles and these are often associated with failure to ovulate and a woman may then present with infertility or sub fertility and around this time in life weight gain is common. Moving after the reproductive time of life, women are at increased risk of diabetes, hyper-tension, raised blood pressure, and importantly there is an increased risk of cancer of the lining of the uterus.

Are you able to say what causes PCOS [and whom it is most likely to affect]?

Over the last 10 to 15 years Penny, it has become clear that there is a strong genetic component to PCOS, and what has also become clear more recently is that the key hormonal abnormality in PCOS is insulin resistance. Women who are insulin resistant have a higher level of insulin in their blood, the importance of this is that this raised level of insulin affects production of the male hormones and these hormones in turn lead to abnormal production of follicles in the ovary and this in turn leads to typical ultrasound appearances of polycystic ovaries.

How is it diagnosed?

The key investigation is a pelvic ultrasound scan, the purpose of which is to look at the morphology or structure of the ovaries. A number of hormone tests are also performed and the key hormone tests that are performed are insulin resistance, classically a fasting insulin level and the levels of the male androgen hormone levels.

So can you talk a little bit about the treatments currently available?

Certainly, the key advice is dietary modification and exercise, which together lead to weight loss, that’s unquestionalbly the single most important piece of advice the doctor can give to his patient. Turning to specific conditions or complaints, if the woman needs contraception, the oral contraceptive pill would be suitable, particularly one that has a low level of the male hormone, and several brands of these are available. If a woman complains of acne or excessive body hair there are simple treatments such as shaving, bleaching, waxing or using hair removal creams as far as drug treatment for these go, there is a diuretic called Spironolactone which is well established in the treatment for this condition.

PCOS can affect a woman’s fertility. Can you tell us more about why this is and what can be done about it?

Indeed PCOS can affect fertility in two key ways, a common presentation of PCOS is an-ovulation – failure to ovulate., But it is also important to bear in mind that even in those women who do ovulate, data from IVF cycles show that there is a poorer quality of the egg. So there are two ways: failure to ovulate and decreased egg quality

And the treatment for such women?

Clearly if a woman does not ovulate she requires ovulation induction, the standard first line treatment for this is a tablet called Clopmiphene citrate or Clomid. This tablet is taken for 5 days of the cycle and it would be standard practice to continue with Clomid for between 6 to 9 cylcles. If a woman does not conceive despite using Clomiphene, the options are two fold. One option is surgery and the surgical treatment is called laparoscopic ovarian diathermy, some doctors refer to this as laparoscopic ovarian drilling. This does involve a laparoscopy which is the insertion of a telescope into the abdominal cavity. Diathermy is heat energy and the basis of this treatment is that heat will destroy a small portion of the ovary and this in turn will, in many cases, lead to the resumption of ovulation. The alternative to surgical intervention if Clomiphene has not worked, is to use injections of drugs known as gonadatrophins. Finally there is of course IVF.

And I understand there is increasingly use of Metformin, can you tell me a little bit more about how that works.

Metformin is a tablet, it is a class of drug known as insulin sensitising agents. It has also been widely used for many decades to treat diabetes. How Metformin works is that it decreases production of insulin and it does this by decreasing the production of glucose by the liver from the reproductive point of view Metformn has a direct affect on the ovary. It has been increasingly prescribed to women with polycystic ovary syndrome in order to decrease their levels of insulin and the decreased levels of insulin lead to a decreased level of androgens – the male hormones , the consequence of decreasing a woman’s insulin levels and decreasing her androgen levels is that she may resume ovulating spontaneously or naturally and Metformin is also used increasingly to treat hirsuitism – excessive facial hair.


You are currently involved in a research project, funded by WoW, looking at the links between PCOS, blood clotting and recurrent miscarriages. Are you able to tell us more about this and what you hope to gain from this research

Yes, our group at St Mary’s were very fortunate in being awarded a grant by Wellbeing in 2007 to investigate as you said the relationship between polycystic ovaries and miscarriage. The basis for this research is that whilst we know that a quarter of all women have polycystic ovaries on scan, amongst women with recurrent miscarriage 40-45% have polycystic ovaries so this ovarian structure is much more common in women with miscarriage, we took our initial studies a step further by looking at the pregnancy outcome of women with polycystic ovaries and miscarriage and we found that these women did significantly worse than women with so called normal ovaries. So that is the actual basis for the study. What we are actually looking at in detail, is the relationship between insulin levels, and we’ve talked quite a bit about insulin in this podcast, insulin levels and impairment of blood clotting breakdown. And blood-clot breakdown is one of the key methods by which the embryo implants or invades. Our initial data is very encouraging and we would anticipate that on the basis of this grant from Wellbeing within 18 months we will be able to start a drug treatment trial for women with polycystic ovaries and recurrent miscarriage.

What thought would you like to leave sufferers of PCOS with?

I think the most important thing is a diagnosis of PCOS carries life long implications for a woman well beyond the reproductive years, but it is also important that a woman feels empowered. By far and away the most effect intervention in PCOS are lifestyle changes, by dietary modification, by moderate exercise, not necessarily excessive, but moderate exercise, this can make significant changes to the hormonal environment and this can lead to a significantly reduced lifetime risk for heart disease, diabetes and for cancer of the lining of the uterus.

Thank you for that thought Raj and I hope that PCOS sufferers will find your insights today useful.

 

PCOS is one of the leading causes of fertility problems and can be a debilitating condition, but it is notoriously difficult to diagnose. Read here about the true facts behind PCOS and the important differentiation between PCOS and PCO.

If I have polycystic ovaries that means I have PCOS ?

No. PCO is a common condition and should not be confused with PCOS. Less than half of women with PCO will have the Syndrome (PCOS).

PCOS makes you hairy, overweight and spotty?

Not all women experience the entire range of symptoms of PCOS. However common symptoms do include: excessive hair growth on face and body, a tendency to put on weight and acne, all of which can be addressed with lifestyle changes or the appropriate drugs.

PCOS gives you diabetes

In the long term there are a number of risks associated with PCOS including an increased risk of diabetes. If you have PCOS you should discuss the management of the condition with your doctor or specialist, who may recommend a specific treatment. There are also many adjustments you can make to your lifestyle to reduce the risks.

I won’t be able to get pregnant if I have polycystic ovaries or PCOS?

PCO is common and should not affect your chances of becoming pregnant. For women with PCOS who are having difficulties becoming pregnant, a medication in tablet form called clomiphene (Clomid) can be used to induce ovulation. In addition, weight loss can normalise menstrual cycles and often increases the possibility of pregnancy in women with PCOS.

Metformin is a new drug that can cure PCOS?

Metformin (glucophage) has been used for some time in the treatment of type 2 diabetes. It affects the action of insulin and is useful in reducing the symptoms of PCOS.

To find out about our research follow these links:
Polycystic ovaries and miscarriage
Insulin resistance in PCOS

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx