Hi there, I have polysystic ovaries but I
din't have pcos. My docotr saw it when he
gave me a scan and said it can effect
fertility but it obviously didn't affect
mine as I got pregnant 3 times in 2
years.
Here is a bit of info from this website;
http://ww
w.Netdoctor.Co.Uk/womenshealth/facts/pcos.
Htm
what is polycystic ovary syndrome?
Polycystic (literally, many cysts) ovary
syndrome (pcos or pco) is a complex
condition that affects the ovaries (the
organs in a woman's body that produce
eggs).
In pcos, the ovaries are bigger than
average, and the outer surface of the
ovary has an abnormally large number of
small follicles (the sac of fluid that
grows around the egg under the influence
of stimulating hormones from the brain).
In pcos, these follicles remain immature,
never growing to full development or
ovulating to produce an egg capable of
being fertilised. For the woman this
means that she rarely ovulates (releases
an egg) and so is less fertile. In
addition, she does not have regular
periods and may go for many weeks without
a period. Other features of the condition
are excess weight and excess body hair.
The condition is relatively common among
infertile women and particularly common
among women with ovulation problems (an
incidence of about 75 per cent). In the
general population, around 25 per cent of
women will have polycystic ovaries seen on
ultrasound examination but most have no
other symptoms or signs of pcos and are
perfectly healthy. The ultrasound
appearance is also found in up to 14 per
cent of women on the contraceptive pill.
What causes pcos?
While it is not known if women are born
with this condition, pcos seems to run in
families. This means that something that
induces the condition is inheritable, and
thus influenced by one or more genes.
Interestingly, when pcos is passed down
the man's side of the family, the men are
not infertile, but they do have a tendency
to become bald early in life, before the
age of 30. Ongoing research is trying to
clarify whether there is a clearly
identifiable gene for pcos. It seems
likely that in the future one or two genes
will be identified that play a fundamental
role in determining a woman's likelihood
of developing this condition.
Even if pcos has a genetic basis, it is
likely that not all women with the gene or
genes will develop the condition. It is
more likely to develop if there is a
family history of diabetes (especially
type 2, the less severe type usually
controlled by tablets), or if there is
early baldness in the men in the family.
Women are also more at risk if they are
overweight. Maintaining weight or body
mass index (bmi) below a critical
threshold is probably very important to
determine whether some women develop the
symptoms and physical features of the
condition. Just how much weight (or what
level of bmi) is difficult to say because
it will be different for each individual.
Certainly, for patients who are considered
obese (with bmi greater than 30) or
overweight (bmi 25 to 30), weight loss
improves the hormonal abnormalities and
improves the likelihood of ovulation and
thus pregnancy.
Can pcos be prevented?
If there is a genetic influence, then some
people are more likely to get pcos than
others. However, it seems likely that you
cannot alter your predisposition to pcos.
There is no current proof of any benefit
of preventative weight loss, but the best
advice for overall health is to maintain a
normal weight or bmi, especially if you
have strong indicators that pcos could
affect you. These indicators are:
a tendency in the family towards
non-insulin dependent (type 2) diabetes.
A tendency towards early baldness in the
men in the family (before 30 years of
age).
The knowledge that a close relative
already has pcos.
What are the symptoms?
The ways in which pcos shows itself
include:
absent or infrequent periods
(oligomenorrhoea): a common symptom of
pcos. Periods can be as frequent as every
five to six weeks, but might only occur
once or twice a year, if at all.
Increased facial and body hair
(hirsutism): usually found under the chin,
on the upper lip, forearms, lower legs and
on the abdomen (usually a vertical line of
hair up to the umbilicus).
Acne: usually found only on the face.
Infertility: infrequent or absent periods
are linked with very occasional ovulation,
which significantly reduces the likelihood
of conceiving.
Overweight/obesity: a common finding in
women with pcos because their body cells
are resistant to the sugar-control hormone
insulin. This insulin resistance prevents
cells using sugar in the blood normally
and the sugar is stored as fat instead.
Miscarriage (sometimes recurrent): one of
the hormonal abnormalities in pcos, a
raised level of luteinising hormone (lh -
a hormone produced by the brain that
affects ovary function), seems to be
linked with miscarriage. Women with
raised lh have a higher miscarriage rate
(65 per cent of pregnancies end in
miscarriage) compared with those who have
normal lh values (around 12 per cent
miscarriage rate).
These symptoms are related to several
internal changes.
Hormonal abnormalities, including:
raised luteinising hormone (lh) in the
early part of the menstrual cycle.
Raised androgens (male hormones usually
found in women in tiny amounts).
Lower amounts of the blood protein that
carries all sex hormones
(sex-hormone-binding globulin).
A small increase in the amount of insulin
and cellular resistance to its actions.
Characteristic changes in the appearance
of the ovaries on ultrasound scan. The
ovaries are polycystic, with many small
follicles scattered under the surface of
the ovary (usually more than 10 or 15 in
each ovary) and almost none in the middle
of the ovary. These follicles are all
small and immature, generally do not
exceed 10mm in size and rarely, if ever,
grow to maturity and ovulate.
Most women with pcos will have the
ultrasound findings, whereas the menstrual
cycle abnormalities are found in around 66
per cent of women and obesity is found in
40 per cent. The increase in hair and
acne are found in up to 70 per cent
whereas the hormone abnormalities are
found in up to 50 per cent of women.
It is likely that there are different
stages of the disease throughout life.
Younger women tend to have substantial
difficulties with their periods, whereas
older women have other problems such as
diabetes and hypertension (high blood
pressure), though their period patterns
tend to become more regular.
Women with pcos also have an increased
risk of strokes and heart attacks, but
their death rate from these conditions is
not increased (wild et al, 2000).
Women with pcos may also have an increased
risk of endometrial cancer (cancer of the
lining of the womb), particularly if they
have infrequent or absent periods.
How is pcos diagnosed?
The diagnosis is based on the patient's
symptoms and physical appearance. If the
diagnosis seems likely because the
patient's history contains many of the
symptoms described already, certain
investigations are done to provide
confirmatory evidence or to indicate
another cause for the symptoms.
These include:
blood tests such as:
female sex hormones (at a certain point in
the cycle if possible)
male sex hormones
sex-hormone-binding globulin
glucose
thyroid function tests
other hormones, eg prolactin.
Ultrasound examination.
Your own gp can do the initial blood
investigations, ensuring they are carried
out at the correct time of the cycle if
appropriate. Your gp may be able to
arrange an ultrasound scan.
Once the diagnosis is made, nothing more
needs to be done for some women, eg if
their fertility is not an issue, if their
weight is within normal limits, and if
they do not have excess body hair.
If any of the symptoms are an issue, then
further advice and treatment, and possibly
specialist referral is needed.
What else could it be?
The other conditions likely to cause
abnormal periods include raised levels of
prolactin and of thyroid stimulating
hormone (tsh). Both these hormones are
produced from a particular part of the
brain, the anterior pituitary.
Raised prolactin levels can occur together
with headaches and some disturbances of
vision whereas raised tsh levels indicate
low thyroid hormones (hypothyroidism).
Both these conditions lead to suppressed
ovulation and infertility.
Increased hair and acne reflect an
increase in male hormones (androgens) in
the blood. Other conditions can cause
such an increase.
Rarely, adrenal disorders or tumours cause
increased androgens. In these conditions,
hirsutism usually develops quite rapidly;
previously normal periods may also stop
and, occasionally, muscle weakness occurs.
Loss of, or changes in, female aspects of
body shape and appearance (secondary
sexual characteristics), especially
reduction in breast size, may also occur.
As the androgen excess progresses, the
voice can deepen and the clitoris can
increase in size (clitoromegaly). If
these serious medical disorders are
present, the male hormone levels will be
considerably increased, way above those
found in pcos, and specialist treatment
should be arranged.
What can you do for pcos?
There are several things that an
individual can do if they have a tendency
towards developing some or all of the
elements of pcos. Much of this involves
lifestyle changes to ensure that your
weight is kept within normal limits (bmi
between 19 and 25).
In addition, because there is a likelihood
of developing diabetes in later life and a
slightly higher risk of heart disease,
low-fat and low-sugar options should be
considered when making choices about what
to eat or to drink.
Weight loss, or maintaining weight below a
certain level, will have the short-term
benefit of increasing the likelihood of
successful treatment and the long-term
benefits of reducing the risk of diabetes
and heart disease (galtier-dereure et al,
1997).
What can your doctor do?
Your family doctor will be able to provide
many of the drug treatments available
(although these are probably best taken in
consultation with a specialist).
Treatments aim to improve several aspects
of pcos, including:
fertility, via the stimulation of
ovulation
reduction of the insulin resistance
reduction of the increased hair.
Treatments
the range of treatments available and
their application are listed in tables 1
and 2.
Table 1 deals with the treatments for
improving fertility in women with pcos
(homberg, 1998; pirwany et al, 1999;
farquhar et al, 2000; hughes et al, 2000a;
hughes et al, 2000b; hughes et al, 2000c).
Table 2 deals with the treatments for
other features of pcos including
hirsutism, irregular or absent periods and
obesity. The evidence in favour of using
of these medications to improve symptoms
is not strong (lee et al, 2000).
Table 1: treatments to improve fertility
in women with polycystic ovary syndrome
drug and mode of action benefits risks
effects on life quality
clomifene (eg clomid): mild stimulant of
ovarian function (hughes et al, 2000a).
Effective method to achieve ovulation. 1.
Very low risk of ovarian hyperstimulation
syndrome. 1. Simple easy method of
treatment with tablets to be taken by
mouth, for five days each month.
2. Possible risk of multiple pregnancy if
several mature follicles develop. 2.
Minimal effects while taking tablets,
though some develop headaches.
3. Increased risk of ovarian tumours in
women having more than 12 cycles of
treatment. 3. Obvious benefit if
pregnancy ensues (pregnancy also lowers
the increased risk of ovarian tumour back
to that of the normal population).
Gonadotrophin injections: direct
stimulation of the ovarian follicles to
grow. Ovulation rates of over 90 per cent
in most women and pregnancy rates of 20-25
per cent per cycle. 1. Ovarian
hyperstimulation syndrome. 1. Require
daily injections of hmg or fsh derived
from urine or recombinant fsh (hughes et
al, 2000c).
2. Multiple pregnancy if many mature
follicles develop. 2. Several studies
suggest the benefits of taking a second
drug in conjunction. This should suppress
lh and improves the chances of an ongoing
pregnancy.
Metformin (eg glucophage): many actions -
eg reduction of male steroid production by
the ovaries. Improves the uptake of
sugars into cells by insulin. Ovulation
rates up to 90 per cent of cycles (pirwany
et al, 1999, galtier-dereure et al, 1997).
No significant associated risk.
Considerable gastrointestinal upset
reported - particularly diarrhoea - which
is somewhat improved by reducing the daily
dose.
Gonadotrophin releasing hormone agonists:
stimulate the release of natural sex
hormones from the brain. Lowers lh
concentrations and reduces the likelihood
of miscarriage (homberg, 1998, hughes et
al, 2000b). Needs to be used in
conjunction with fsh injections and
therefore all the above risks also are
present. Gnrh agonists themselves have
little risk in short-term use. .
Table 2: treatments for other features of
polycystic ovary syndrome
pcos feature available treatment comments
raised androgen (male sex hormone) level
metformin (eg glucophage) 1. Metformin
reduces the abnormal findings of raised
androgens and decreased sex-hormone
binding protein in the blood, but it can
cause considerable gastrointestinal upset
- particularly diarrhoea - which is
somewhat improved by reducing the daily
dose. It is less effective in women of
normal weight and does not improve
hirsutism.
Irregular periods metformin 1. Return of
periods in 90-95 per cent of women.
Obesity metformin 1. Several studies have
examined the effect on weight loss; the
majority support its effectiveness.
Hirsutism combined oral contraceptives,
especially containing the anti-androgen
cyproterone acetate (eg dianette). 1.
These increase the levels of the sex
hormone carrier in the blood, leaving less
androgen free to cause hirsutism.
2. It may take six months before any
noticeable improvement occurs and two to
three years to achieve the maximum benefit
from anti-androgens because of the length
of the growth-cycle of hair.
Hirsutism finasteride 1. Finasteride
reduces the amount of hair by preventing
androgen getting into cells. It can cause
headache and depression, and contraception
is essential to avoid accidental exposure
to a foetus. It is useful as a
second-line drug for the treatment of
excess hair but is not licensed for this
purpose, and some pharmacies have made
inappropriate comments to my patients when
filling prescriptions, affecting their
likelihood of taking the treatment.
Endometrial cancer (cancer of the womb
lining) progestogens, medroxyprogesterone
acetate. 1. Stops endometrium (womb
lining) from developing, and counteracts
any tendency towards cell abnormalities
and cancer. Occasional bloating and fluid
retention occur.
The increased risk of endometrial cancer
is thought to be due to certain hormonal
abnormalities that result in continuous
stimulation of the lining of the womb by
oestrogen. However, the mild increase in
insulin found in these women may also have
negative effects.
It does seem sensible to advise women with
absent or very infrequent periods to take
occasional progestogen therapy to 'oppose'
the oestrogen and minimise the risk of
endometrial cancer.
Non-drug treatments
ovarian diathermy (surgery that uses heat
to alter ovarian function) is thought to
reduce the amount of androgen secreting
tissue in the ovaries, leading to
resumption of ovulation in up to 80 per
cent of women. The risks include those of
having a laparoscopy and a theoretical
risk of ovarian damage from the diathermy.
The benefits include resumption of
ovulation in a simple manner, with effects
lasting six to nine months (farquhar et
al, 2000; homberg, 1998).
There is a range of non-drug treatments
available for hirsutism. Once a serious
increase in male hormone levels has been
excluded, then local cosmetic options can
safely be considered. These include:
bleaching
depilatory preparations
waxing
plucking
laser hair removal
electrolysis
shaving.
Each is usually effective but expert
advice should be taken, because each
method has its own problems.
Bleaching and depilatory preparations can
occasionally cause a local allergic
reaction.
Waxing and plucking often break the hair
shaft rather than actually remove it from
the hair follicle and, therefore, should
be considered to be little more effective
than shaving.
Electrolysis and laser hair removal
usually give the most prolonged action but
both are expensive and cannot tackle large
areas of the skin. Electrolysis is
painful and laser removal may not be
permanent.
Damage to skin or follicles can also occur
with either. Waxing, plucking and shaving
can lead to inflammation and infection of
hair follicles, requiring topical
antibiotic creams.
Sugaring is less likely to provoke this
result than waxing. Best results will be
obtained from shaving if hypoallergenic
shaving soaps and razors are used. There
is no evidence that plucking, waxing or
shaving will encourage increased hair
growth.
What is the outlook?
Living with pcos means different things
for different women. This is because
women experience the condition in
different ways and have more or less
severe symptoms depending on their
situation. In addition, as women get
older, some symptoms change with age;
hirsutism become less as hair distribution
patterns change with advancing age and as
the male hormones in the blood revert to
more normal levels (winters et al,
2000).
Women with pcos are more prone to some
serious conditions. These include an
increase in the likelihood of developing
diabetes (usually type 2 diabetes
(non-insulin dependent diabetes) and of
developing cancer of the womb lining
(endometrial cancer).
They also are more at risk of hypertension
(high blood pressure) and high
cholesterol, though if weight is
controlled, high blood pressure is less
likely to occur (wild et al, 2000).
Therefore, it makes sense to watch for
symptoms suggestive of these conditions
and to see your doctor should any
suspicious symptoms be present.
For endometrial cancer, these include
irregular spotting or bleeding in the 40
to 50 year age group or any bleeding after
themenopause. For diabetes, these include
unusual thirst requiring large amounts of
fluids, tiredness, and passage of
increased amounts of urine, particularly
at night.
