Polycystic ovaries; Polycystic ovary disease; Stein-Leventhal syndrome; Polyfollicular ovarian disease

Causes, incidence, and risk factors

PCOS is linked to changes in the level of certain hormones:

• Estrogen and progesterone, the female hormones that help a woman’s ovaries release eggs
• Androgen, a male hormone found in small amounts in women

It is not completely understood why or how the changes in the hormone levels occur. The changes make it harder for a woman’s ovaries to release fully grown (mature) eggs.  Normally, one or more eggs are released during a woman’s period. This is called ovulation. In PCOS, mature eggs are not released from the ovaries. Instead, they can form very small cysts in the ovary.

These changes can contribute to infertility. The other symptoms of this disorder are due to the hormone imbalances.

Most of the time, PCOS is diagnosed in women in their 20s or 30s. However, it may also affect teenage girls. The symptoms often begin when a girl’s periods start. Women with this disorder often have a mother or sister who has symptoms similar to those of polycystic ovary syndrome.

Symptoms

Symptoms of PCOS include changes in your period (menstrual cycle).  Some changes are:

• No period after you have had one or more normal ones during puberty (secondary amenorrhea)
• Irregular periods, that may come and go and may be very light to very heavy

PCOS can cause you to develop male-like characteristics. This is called virilization. Symptoms include:

• Body hair growing on the chest, belly, face, and around the nipples
• Decreased breast size
• Enlargement of the clitoris
• Thinning of the hair on the head, called male-pattern baldness
• Voice gets deeper

You may also have skin changes:

• Acne that gets worse
• Dark or thick skin markings and creases around the armpits, groin, neck, and breasts

Signs and tests

Your doctor or nurse will perform a physical exam. This will include a pelvic exam. This may reveal:

• Swollen ovaries
• Swollen clitoris (very rare)

The following health conditions are common in women with PCOS:

• Diabetes
• High blood pressure
• High cholesterol
• Weight gain and obesity

Your doctor or nurse will check your weight and body mass index (BMI) and measure your belly size.

Blood tests can be done to check hormone levels. These tests may include:

• Estrogen level
• FSH level
• LH level
• Male hormone (testosterone) level
• 17-ketosteroids

Other blood tests that may be done include:

• Fasting glucose (blood sugar) and other tests for glucose intolerance and insulin resistance
• Lipid level
• Pregnancy test (serum HCG)
• Prolactin level
• Thyroid function tests

Your doctor may also order the following imaging test or surgeries to look at your ovaries:

• Vaginal ultrasound
• Pelvic laparoscopy

Treatment

Weight gain and obesity is common in women with PCOS. Losing weight can help treat the hormone changes and health conditions such as diabetes, high blood pressure, or high cholesterol.

Losing just 5% of your body weight can help your hormone imbalance and may make it easier to get pregnant. For an 160 pound woman, that’s just 8 pounds!

Your doctor may recommend birth control pills to make your periods more regular. Such medicines may also help reduce abnormal hair growth after you take them for a few months.

A diabetes medicine called glucophage (metformin) may also be recommended to:

• Make your periods regular
• Prevent type 2 diabetes
• Help you loss weight when you follow a healthy diet

Other medicines that may be prescribed to help make your periods regular and help you get pregnant are:

• LH-releasing hormone (LHRH) analogs
• Clomiphene citrate, which helps your ovaries grow and release eggs

Your doctor or nurse may also suggest other treatments for abnormal hair growth. Some are:

• Spironolactone or flutamide pills
• Eflornithine cream

Permanent hair removal options include:

• Electrolysis
• Laser hair removal – works best on very dark hair that covers large areas

Treatments can expensive and multiple treatments may be needed.

A pelvic laparoscopy may be done to remove to remove or alter an ovary to treat infertility. The effects are temporary.

Expectations (prognosis)

With treatment, women with PCOS are usually able to get pregnant. There is an increased risk of high blood pressure and gestational diabetes during pregnancy.

Complications

Women with PCOS are more likely to develop:

• Endometrial cancer
• Infertility
• Breast cancer (slightly increased risk)

Calling your health care provider

Call for an appointment with your health care provider if you have symptoms of this disorder.

References

1. Bulun SE, Adashi EY. The physiology and pathology of the female reporductive axis. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 17.
2. Radosh L. Drug treatments for polycystic ovary syndrome. Am Fam Physician. 2009;79:671-676.
3. Lobo RA. Hyperandrogenism: Physiology, etiology, differential diagnosis, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 40.

Review Date: 2/26/2012.Reviewed by: Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington; Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Cochrane Database of Systematic Reviews: Plain Language Summaries.

The effect of a healthy lifestyle for women with polycystic ovary syndrome

First published: July 6, 2011; This version published: 2011; Review content assessed as up-to-date: September 07, 2010.

Plain language summary

Polycystic ovary syndrome (PCOS) is a very common condition affecting 4% to 18% of women. Being overweight worsens all clinical features of PCOS. These clinical features include reproductive manifestations such as reduced frequency of ovulation and irregular menstrual cycles, reduced fertility, polycystic ovaries on ultrasound, and high male hormones such as testosterone which can cause excess facial or body hair growth and acne. PCOS is also associated with metabolic features and diabetes and cardiovascular disease risk factors including high levels of insulin or insulin resistance and abnormal cholesterol levels. PCOS affects quality of life and can worsen anxiety and depression either due to the features of PCOS or due to the diagnosis of a chronic disease. A healthy lifestyle consists of a healthy diet, regular exercise and achieving and maintaining a healthy weight. This review identified six studies with 164 participants that assessed the effects of a healthy lifestyle in women with PCOS. In this review, there were no studies reporting on fertility outcomes such as pregnancy, live birth and miscarriage. While some studies reported on menstrual regularity and ovulation, the findings were reported in a variety of ways and it was not possible to estimate the overall effects of lifestyle on these outcomes. Current evidence suggests that following a healthy lifestyle reduces body weight and abdominal fat, reduces testosterone and improves both hair growth, and improves insulin resistance. There was no evidence that a healthy lifestyle improved cholesterol or glucose levels in women with PCOS.

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Treatment of PCOS.

1.Medications

2.Fiber

3. Low GI program

4.Reduce stress.

5.Essential fatty acids

6.Drink enough water.

7.Antioxidants

8.Herbal remedies.

9.Detoxification.

1. Medications:

-Anti-androgen medications: Aldactone, Tagamet.

-Testosterone metabolism blockers : Propecia (finasteride)

-Medications to lower blood sugar: Metformin is the most successful

-Gonadotrophin-Releasing Hormone Antagonists: Lupron

-Hair growth stimulators: Rogaine solution (Minoxidil)

-Hair metabolism inhibitors: Vaniqa cream (eflornithine)

-Menstrual regulators: Progestins, BCP. Progesterone

-Ovulation Inducers: Clomid, Pergonal, Follistim, Pregnyl (HCG)

2. Fiber:

-Lowers blood sugar, blood pressure and cholesterol.

3. Low glycemic index diet

– Weight loss and Exercise.

– study revealed that after 6 months on the above, women lost 11% central fat, 71% improvement in insulin sensitivity, 33% decrease fasting insulin level, 39 % decrease LH, and 50% of women started ovulating. (Ref Huber-Bucholz : Jrnl Clin Endoc Metab 1999.)

4. Reduce Stress.

– Cortisol stimulates the release of glucose, fats and amino acids for the production of energy in the body.

-During times of stress, cortisol, insulin and cholesterol  levels rise in the body. This exacerbates the symptoms of PCOS.

5. Essential Fatty Acids. (Omega-3,6 and 9 mainly)

-EFA slow down the absorption of carbohydrates into the blood stream.(Kasim Journ Clin Endoc Metab 2004)

6. Drink enough water.

– people who drink 5-8 glasses of water a day have fewer heart attacks. (Ref: Chan,J Amer Jour Epidemiology 2002)

7. Nutritional treatment of Insulin Resistance.

-Chromium Picolinate (400-600 micrograms): Decreases sugar cravings and improves insulin sensitivity.

-Lipoic Acid (200-600 mg): Improves insulin sensitivity and prevents neuropathy.

-CLA (1,000-3,000 mg): Improves insulin sensitivity.

-Zinc (25-50 mg): Helps balance blood sugar levels.

-Taurine (1,000-3,000 mg) : Increases activity of insulin receptor and improves sensitivity to insulin.

-Magnesium (400-800 mg): Improves glucose uptake.

– Biotin (4-8 mg): Increases insulin sensitivity.

-Vitamin D (400 – 2,000 IU) : Helps pancreas release insulin.

-Co-enzyme Q10 (30-300 mg): Provides energy for metabolic pathways.

-Inositol; decreases insulin resistance.

– Lentils, Chickpeas and Broccoli all reduce insulin levels.

Reference all the above: Pamela Smith. “What you must know about Vitamins, Minerals and Herbs, and More” 2008.

8. Herbal therapies.

-Fenugreek: Interferes with absorption and digestion of sugars. (Uemura,T. “Diosgenin present in fenugreek improves glucose metabolism” Mol Nutr food res 2010.)

-Cinnamon: Improves glucose utilization and increases insulin receptor sensitivity.

-Gymnema Sylvestre: Improves insulin sensitivity and interferes with the absorption of sugar.

-Saw Palmetto: Inhibits conversion testosterone to DHT. Reduces Acne and Hirsutism. (200 mg BD)

-Nettle Root: reduces testosterone by binding to SHBG. 300 mg BD. Must be the root.

– Green tea: Increases SHBG, lowering testosterone. Promotes weight loss. (Nagata Nutr Cancer 1998. Trial of women with PCOS showed weight loss of 2.4 % (Journ Soc Gynecol Investig 2006)

-Licorice root: Decrease testosterone level. 3.5 gms of liquorice. (Amanin D Exp Clin Endoc Diabetes 2002. Also Steroids 2005

-spearmint tea: Lowers testosterone level, improves hirsutism. (Grant P.Phytother Res 2010;24:186-88)

– D-chiro-inositol: 1200 mg 4 times daily. Lowers insulin and testosterone levels, increasing chances of ovulating. (Nestler J et al. NEJM 1999)

-Maitake mushroom extract. Study compared patients with PCOS given Mushroom vs clomiphene. After 3 cycles -76% mushroom group ovulated, vs 93% with clomiphene. (Chen J ; Jrnl Altern comple med 2010;16(12);1295-99)

Best reference book for Patients: The PCOS protection Plan by Colette Harris and Theresa Cheung.  Hay House.