Polycystic ovarian syndrome (PCOS) affects approximately 10% of women of reproductive age and the incidence is much higher in infertile women. The hallmark diagnostic feature of PCOS is chronically elevated androgen hormone levels and ovaries covered with numerous small unruptured cysts. Androgens are male hormones such as testosterone.
At least two of the three characteristics below are required for the diagnosis of PCOS.
- Oligomenorrhea (menstrual interval greater than 35 days or 8 or less menstrual cycles per year)
- Clinical or laboratory exam consistent with androgen excess (excess body hair, acne, scalp hair loss, or elevated blood levels of testosterone, DHEAS, low sex hormone binding globulin)
- Ultrasound evidence of polycystic ovaries (12 or more follicles at 2-8 mm or increased ovarian volume)
Elevated androgen levels are responsible for many of the symptoms of PCOS including hirsuitism (excess body hair), sometimes a lowering of the voice, thinning hair on the head, irregular or no ovulation, a classic pear shaped body appearance, and infertility. Women with PCOS are often obese; however, PCOS occurs in women of all weights.
Women with PCOS are often hyperinsulinemic meaning that they have chronically elevated levels of insulin. The cells within the pancreas do not respond normally to glucose and overproduce insulin. This excess insulin causes the ovaries to increase androgen production and decrease serum sex hormone-binding globulin. Elevated androgens impede the growth of ovarian follicles and lead to lack of ovulation. Lack of ovulation will cause amenorrhea and increases the risk of endometrial hyperplasia.
The current “first line” treatments for PCOS may be Clomid®, metformin, FSH, or a combination of these products. Metformin (an insulin sensitizing drug) works to establish a “physiologically normal state” by increasing the cells sensitivity to insulin causing them to respond normally to glucose. Once the androgen levels decrease, normal ovulation will often result.
Many fertility specialists are prescribing metformin for the long term management of potential PCOS health complications. These complications can include cardiovascular disease and Type II diabetes.
Clomid®, which competes for estrogen receptors at the hypothalamus, is often effective in regulating ovulation. FSH works by directly stimulating the ovaries. PCOS patients should only be treated by a reproductive endocrinologist infertility specialist who has extensive experience in the use of gonadotropins (FSH, Gonal-F, Follistim, Repronex, etc.). This is because PCOS patients are notorious for exaggerated responses to FSH stimulation and are prone to hyperstimulation syndrome (OHSS). OCSS can be very serious leading to complications that require hospitalization. The Serono and Organon Web sites have extensive discussions of OCSS.
At one time, surgery was a popular treatment for PCOS but it is now reserved for the most severe cases that are unresponsive to other therapies. Surgery involves cutting, or removing, sections of the ovary often with a laser to lower androgen production.