Polycystic ovary syndrome (PCOS) or polycystic ovarian syndrome, is a common hormonal disorder that affects 5-13% of women of reproductive age and is associated with a lack of ovulation (anovulation) and excessive production of male hormones (androgens). It is a complex disorder that is represented by a collection of signs and symptoms .

What are the symptoms and signs of PCOS?

A syndrome is a collection of signs and symptoms that point to a particular diagnosis. This means that no single sign or symptom can be diagnostic of the condition. In addition, not all women with the diagnosis will experience the same symptoms. The range of symptoms for women who have PCOS may include:

  • Irregular, infrequent menstrual cycles (oligomenorrhea)
  • Hirsutism (increased hair growth)
  • Hair thinning on the scalp
  • Acne
  • Infertility
  • Weight gain

Hyperandrogenism resulting primarily from excess male hormone (androgen) production is also a major feature of polycystic ovary syndrome. The increase in production happens mainly in the ovaries, and to a lesser extent, in the adrenal glands.

Many women with PCOS have ovaries that are enlarged with many small cysts (fluid-filled sacs) that are visible through an ultrasound examination. These cysts are thought to be eggs that are not expelled at ovulation This is called a polycystic ovary. However, it is not necessarily seen in all women with PCOS.

How is PCOS diagnosed?

Because of the variable nature of PCOS, a diagnosis is made by a woman having at least two of the following three characteristics:

  1. The inability to release an egg from the ovaries on a regular cyclic basis (delayed or irregular menstrual cycle) or a long absence of ovulation (chronic anovulation)
  2. Increased male hormone levels and/or an increase in hair in the midline of the body (signs of hyperandrogenism)
  3. Polycystic-appearing ovaries on an ultrasound

How is infertility in women with PCOS treated?

Lifestyle changes play a major role in the management of PCOS. Diet and exercise that result in weight loss (at least 10%) improves the frequency of ovulation, enhances the ability to get pregnant, improves fertility, lowers the risk of diabetes, and lowers androgen levels in many women with PCOS.

Infertility is a symptom seen in 70-80% of PCOS patients. There are general considered to be three lines of treatment for infertility.

First-Line Treatment

Infrequent or absent ovulation (annovulation) is one of the major causes of infertility in women with PCOS, provided there is no other simultaneously contributing factor. Because of this, the first line of treatment is to attempt to induce ovulation. Along with lifestyle changes, ovulation may often be induced with oral fertility medications including:

  • Clomiphene citrate - An oral medication, also known as Clomid, combined with timed intercourse. The rate of successful ovulation may be around 75-80%, and within six cycles, the pregnancy rate is between 60 and 70%.
  • Letrozole - An oral medication, combined with timed intercourse.

Second-Line Treatment

Gonadotropins are associated with a higher risk of ovarian hyperstimulation syndrome (OHSS) which is an overstimulation of the ovaries, and multiple gestation pregnancies. PCOS patients must be monitored very carefully when gonadotropins are utilized.

Third-Line Treatment

In vitro fertilization (IVF) may also be an option for patients with PCOS when other treatments have not been successful.

In Vitro Fertilization (IVF) in PCOS Patients

Approximately 70% of women with PCOS respond to ovulation induction treatment alone. In vitro fertilization (IVF) in women with PCOS is reserved for those who fail to respond to gonadotrophin therapy or who have coexisting infertility factors. Women with PCOS who undergo IVF cycles are likely to respond differently from women with normal functioning ovaries. Certain highlights in this group of women are:

  • Requirement of a longer duration of ovulation stimulation.
  • Ultrasound monitoring during ovulation stimulation has to be more frequent.
  • Risk of OHSS: OHSS is an exaggerated response to ovulation induction medications. It is a syndrome comprising with marked ovarian enlargement, high serum estradiol and fluid collection in the body cavities like the abdomen. At the same time, the risk for clotting in the blood increases.
  • An increased likelihood of having an IVF cycle cancelled.
  • Poorer quality oocytes - often many of the eggs retrieved from PCOS patients are immature and incapable of fertilization. That said, a greater number of eggs are often retrieved from PCOS patients. A meta-study found that because of the increase in numbers, fertilization rates appear similar to non-PCOS patients.
  • Co-treatment with Metformin is being further evaluated for its beneficial effects in IVF for PCOS patients.

Treating PCOS in Woman not Actively Seeking to Become Pregnant

If fertility is not an immediate concern, hormonal therapies are usually successful in temporarily correcting the problems associated with PCOS.

  • Oral contraceptive pills (OCs) are commonly prescribed to reduce hirsutism and acne, maintain regular menstrual periods and prevent endometrial cancer.
  • Medications that decrease androgen action can also be used to improve hirsutism. In addition, hair removal methods including electrolysis and laser may be beneficial in unwanted hair removal.
  • Treatment with medications that increase the body’s sensitivity to insulin, such as metformin, may help improve ovulation and may reduce the risk of developing diabetes or metabolic syndrome.

Overall, treatment for PCOS is individualized to the needs of the individual.

Health Risks Associated with PCOS

There are health implications of PCOS that reach beyond an impact on fertility. Knowing and understanding the health implications and consequences of chronic anovulation is important for those with a diagnosis of PCOS.

  • Lack of ovulation in women with PCOS results in continuous exposure of the endometrium (uterine lining) to estrogen. Estrogen causes excessive thickening of the uterine lining and possible abnormal shedding of the endometrium causing abnormal menstrual bleeding. The excessive stimulation by estrogen without ovulation may lead to uterine cancer or pre-cancer.
  • Metabolic syndrome is more common in women with PCOS. This condition is characterized by a number of conditions including excess wight around the abdomen, cholesterol abnormalities, hypertension, and insulin resistance/diabetes mellitus. These conditions increase the risk of heart disease.

Given the risk associated with the overall metabolic disorder of PCOS, once the diagnosis is established, further medical evaluation is warranted. This generally includes a thyroid, prolactin and androgen hormone assessment, adrenal hormone assessment, a lipid profile, blood sugar evaluation, and endometrial sampling in women whose history indicates potential long-term exposure to unopposed estrogen stimulation.