PCOS Education

Infertility & Reproductive

Medicine of South Broward

Kenneth M. Gelman M.D. F.A.C.E.

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Glossary

Polycystic ovarian syndrome (PCOS) has recently become a hot topic of discussion. In the past two years, no other condition in the field of reproductive medicine has been more popular in both the lay-press and Internet. It was once rarely recognized by people except those affected infertile women who received treatment from Reproductive Endocrinologists. Now, individuals are themselves learning more about the condition than most physicians know. Almost daily, I am asked by a patient about what they have read on the web, heard from a friend or learned from a women’s magazine. It has been fascinating to observe the educational waves of the mass media that have empowered patients with knowledge to recognize and treat this important disorder.

What is PCOS?
Polycystic ovarian syndrome affects approximately 5 million women in the United States, or about 4% of all reproductive-aged women. It is the most common hormone disorder in reproductive-aged women and is the leading cause of female infertility. It is one of the most treatable forms of infertility, yet patients often suffer from it too long because it is unrecognized or mistreated. Many patients are surprised to find that there are effective treatments available for virtually every symptom associated with the condition.

The polycystic ovary contains many small cysts 2 – 6 mm in diameter. In the past, it was diagnosed during surgery when the ovary could be seen. Now, an ultrasound examination can reveal the polycystic nature of an ovary. Since using ultrasound, polycystic ovaries have been observed in 25% of normal women. Hence, it is important to distinguish the findings of polycystic ovaries and PCOS. Polycystic ovaries are a common finding in patients with PCOS, but do not define the condition. Women with PCOS also present with a variety of symptoms. Polycystic ovaries are merely one feature of the polycystic ovarian syndrome.

PCOS is a clinical diagnosis based on irregular ovulation and signs of excessive androgen (male-type hormones) effect. It is called a syndrome because it represents a constellation of clinical symptoms. The diagnosis cannot be established by a single symptom or clinical test alone. Individuals will present with an extreme variety of manifestations. The spectrum may range from a thin woman with occasionally skipped menses to an overweight woman with no menses who suffers from hirsutism acne, diabetes, balding, skin pigmentation and the inability to lose weight no matter how many diets she follows. Table 1 lists the most frequent features of the condition.

Symptoms of PCOS

Clinical Features of PCOS Incidence

Irregular menses 85%

Hirsutism 70%

Obesity 40%

Acne 35%

Skin pigmentation 3%

Irregular menses is a hallmark for an individual who does not ovulate regularly. Since the lack of ovulation is a central feature of the syndrome, many patients will suffer from infertility. Due to the heterogeneity of the syndrome, guidelines have been established to diagnose the condition. In the United States, we diagnose the condition when a patient has irregular menses and symptoms of hyperandrogenemia, such as hirsutism, acne and/or oily skin.

How is PCOS treated?
The most important concept in treating PCOS is first determining what you desire to treat. Since it is a multifaceted disorder, several different treatments are available depending on the symptom you wish to improve. The medicinal treatments for PCOS can be directed at a specific symptom or combined to treat several complaints. But first, the patient and physician must decide on what the therapeutic goals should be.
Generally, the therapeutic options are directed at one or more of the following:

1.Restoring normal menstrual cycles
2.Reducing symptoms of excess hair growth or oily skin
3.Restoring normal fertility
4.Weight reduction

Oral contraceptive pills (OCPs) are the most effective method to correct # 1 and improve # 2. Naturally, they are counterproductive for both # 3 and # 4. OCPs contain estrogen and progesterone. These are the hormones produced by the ovary that govern the normal menstrual cycle. Futhermore, estrogen acts as an antagonists to androgen effects seen in PCOS. There are several agents available to effectively treat # 2. Besides OCPs, a common anti-androgen is the diuretic, spironolactone. Others include finasteride, flutamide and cyproterone acetate. Since hair growth and turnover occur over a long time, the results of decreasing hirsutism with these agents sometimes takes 3 - 6 months to appreciate an effect. Restoring fertility (# 3) requires returning the FSH effect to a predominant role on the ovary. This can be achieved by either reducing the “resistance factors” or merely increasing the FSH until it reaches the elevated threshold required for follicles to grow. Insulin sensitizing agents are the most effective for reducing insulin resistance. These include metformin, rosiglitazone and D-chiroinositol (not yet commercially available). These agents are very effective adjuncts for treating # 4. By reducing insulin levels, the weight promoting stimulus is reduced and the patients finds it easier to lose weight through diet control and exercise.

Two types of fertility drugs exist capable of increasing the FSH level. Clomiphene citrate is the most commonly used. It works by stimulating the pituitary release of FSH. Gonadotropins are the other class of fertility drugs. They are merely purified forms of FSH. The dose of these injectable medications can be adjusted until the threshold is reached causing follicle growth. Often, we use a combination of the above medications to optimize follicular growth to restore fertility. Virtually every patient with PCOS can be treated effectively. Because the symptoms are so diverse, no single treatment fits all conditions. It is essential to recognize the syndrome, determine the desired treatment goals and develop an appropriate treatment plan to achieve those goals.

Polycystic Ovarian Syndrome