Polycystic ovary syndrome

DEFINITION: A complex disorder related to dysfunctional ovulation, endocrine abnormalities, and multiple cysts on the ovary that result in fertility difficulties; also related to obesity and diabetes; poses an increased risk for cardiovascular disease; symptoms of hirsutism may be accompanied by depression or anxiety

ANATOMY OR SYSTEM AFFECTED: Endocrine system, pancreas, reproductive system, skin

SPECIALITIES AND RELATED FIELDS: Dermatology, endocrinology, family medicine, gynecology, nursing, nutrition, obstetrics, pathology, pediatrics, pharmacology, preventive medicine, psychology, public health

CAUSES: Environment and genetic risk factors not yet well defined

SYMPTOMS: Hirsutism, hyperandrogenism, hyperinsulinemia, obesity, infertility, irregular menses

DURATION: Chronic

TREATMENTS: Diet for weight loss; medications, surgery

Causes and Symptoms

Polycystic ovary syndrome (PCOS) seems to be caused by a combination of and environmental factors. Researchers are currently using candidate gene research to try to determine which genetic sequences may lead to susceptibility for PCOS. First-degree relatives of someone with PCOS are at higher risk of developing the condition themselves. Exposure to prenatal may play a role, although this exposure may occur anywhere from the prenatal period through puberty. Additionally, in the prenatal period, the androgens appear to be from the and not the mother.

Hyperinsulinemia and obesity both contribute to higher levels of androgens, called hyperandrogenism. Insulin may directly stimulate the production of androgens from the ovary, or it may indirectly affect androgen levels by inhibiting sex hormone-binding globulins. Obesity is associated with hyperinsulinemia.

The signs and symptoms can be ambiguous. The most common are related to the and include hirsutism (excess facial hair), infertility, and menstrual irregularities. Acne and male-pattern baldness may also occur. The 1990 National Institutes of Health classification of PCOS requires disordered ovulation and clinical or biochemical evidence of hyperandrogenism. In 2003, the Rotterdam European Society of Human Reproduction and Embryology/American Society of Reproductive Medicine consensus workshop included having polycystic but suggested that two of these three symptoms were enough on which to base a diagnosis. Thus, a woman with PCOS may have disordered ovulation and polycystic ovaries with androgen excess, or androgen excess with polycystic ovaries but no disorder in ovulation. However, other scenarios are possible.

Hyperandrogenism can be evaluated through laboratory tests, including levels, sex hormone-binding globulins, and other androgen levels. However, these tests have not always reliably reflected PCOS symptoms. Ultrasound is used to detect the presence of polycystic ovaries and may include an of number and ovary size. Criteria for ultrasound evaluation include having twelve or more follicles that are two to nine millimeters in diameter or ovarian volume greater than ten cubic centimeters.

Treatment and Therapy

The main goal of treatment and therapy is to normalize menstrual cycles and ovulation and, if desired, achieve a successful pregnancy. The least-invasive approach to achieving this goal is weight loss in those who are overweight. Weight loss of 5 to 10 percent has been shown to have a positive impact on symptoms of PCOS—hirsutism, infertility, and menstrual irregularities as well as hyperinsulinemia. This goal can be achieved by a in caloric intake and increased physical activity, although it is difficult to maintain.

Although weight loss is helpful, it may not alleviate all symptoms of PCOS in overweight females. In addition, many but not all of those with PCOS are estimated to be overweight. Medications may be prescribed to achieve menstrual regularity or normalize blood glucose levels. Birth control medications will help to regulate menses if the woman is not trying to conceive. However, they may also result in weight gain and insulin resistance, which would be a negative effect for the PCOS treatment overall. Clomiphene citrate, a selective modulator (SERM), may be prescribed to enhance the chances of conception, if this is desired. However, only 10 percent of women receiving this medication become pregnant. If clomiphene citrate fails to induce conception, then gonadotropins or laparoscopic ovarian surgery may be tried. However, gonadotropin therapy is associated with multifetus pregnancy, which is not found as often with surgery. However, regimens with low doses of gonadotropins have had some success over traditional doses in achieving single pregnancy. If these options fail to produce pregnancy, then in vitro is also an option.

For blood glucose normalization, oral hypoglycemic agents such as the biguanide metformin are usually prescribed. Some studies have suggested this medication may also enhance fertility, although other studies have found no such result. Medical professionals have recommended discontinuing metformin when pregnancy is confirmed. Some suggested that the use of metformin may continue through pregnancy if type 2 diabetes is present. Nonsteroidal antiandrogen medications may help improve the symptoms of androgen excess, although they are not commonly used in adolescents. While several medications may improve hirsutism to some extent, nonpharmacological treatment can also be used, including waxing, electrolysis, bleaching, plucking, and heat or laser therapy.

Perspective and Prospects

First described by Irving F. Stein and Michael L. Leventhal in 1935, PCOS was for a time referred to as the Stein-Leventhal syndrome. At that time, surgical resection of the ovaries was fairly successful treatment, although complications with internal adhesions eventually made other treatments more desirable.

According to the World Health Organization (WHO), the prevalence of PCOS is estimated at about 8 to 13 percent of premenopausal women, with an estimated 70 percent of cases remaining undiagnosed. While women of childbearing age were at one time believed to be the primary group afflicted with PCOS, adolescents are now also being diagnosed with the disorder. The diagnosis is somewhat more difficult because menses are often irregular until at least two years past menarche.

Polycystic ovaries by themselves have no long-term negative effects, although women with polycystic ovaries without the symptoms of the syndrome are at higher risk for hyperstimulation syndrome. Those with PCOS are at higher risk of complications associated with diabetes and disease. Depression and a reduced quality of life have been reported in women with PCOS, possibly as a result of difficulties with conception, dissatisfaction with appearance, and issues associated with chronic disease.

Bibliography

Dunaif, Andrea, et al., eds. Polycystic Ovary Syndrome: Current Controversies, from the Ovary to the Pancreas. Totowa, N.J.: Humana Press, 2008.

Franks, Stephen. “Polycystic Ovary Syndrome.” Medicine 37, no. 9 (September, 2009): 441–444.

Hoeger, Kathleen M. “Role of Lifestyle Modification in the Management of Polycystic Ovary Syndrome.”Best Practice and Research: Clinical Endocrinology and Metabolism 20, no. 2 (June, 2006): 293–310.

MedlinePlus. "Polycystic Ovary Syndrome." MedlinePlus, May 13, 2012.

Norman, Robert J., et al. “Polycystic Ovary Syndrome.” The Lancet 370, no. 9588 (August 25, 2007): 685–697.

"Polycystic Ovary Syndrome." World Health Organization, 28 June 2023, www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome. Accessed 17 Oct. 2024.

"Polycystic Ovary Syndrome (PCOS)." Mayo Clinic, 8 Sept. 2022, www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439. Accessed 7 Apr. 2024.

Radosh, Lee. “Drug Treatments for Polycystic Ovary Syndrome.” American Family Physician 79, no. 671 (April 15, 2009): 671–676.

Singh, Samradhi, et al. "Polycystic Ovary Syndrome: Etiology, Current Management, and Future Therapeutics." Journal of Clinical Medicine, vol. 12, no. 4, 11 Feb. 2023, p. 1454, doi.org/10.3390%2Fjcm12041454. Accessed 7 Apr. 2024.