Polycystic ovarian syndrome (PCOS)

Definition

Polycystic ovary disease is characterized by enlarged ovaries with multiple small cysts, an abnormally high number of follicles at various states of maturation, and a thick, scarred capsule surrounding each ovary.

The syndrome was originally reported by Stein and Leventhal in 1935 when they described a group of women with amenorrhea (absence of menstrual period), infertility

Today, it is known that those with polycystic ovaries may have some, but not necessarily all, of the "classic" symptoms included in Stein-Leventhal syndrome.

Alternative Names

Causes

Polycystic ovary disease is an endocrine disorder, which means normal hormone cycles are interrupted. Hormones direct many functions throughout the body. For example, hormones regulate reproductive functions, including the normal development of eggs in the ovaries. It is not completely understood why or how hormone cycles are interrupted, although there are several working theories.

In polycystic ovary disease, under-developed follicles accumulate in the ovaries. Follicles are sacs within the ovaries that contain eggs. The eggs in these follicles do not mature and, therefore, cannot be released from the ovaries. Instead, they accumulate as cysts in the ovary. This can contribute to infertility. The lack of follicle maturation and the inability to ovulate are likely caused by low levels of follicle stimulating hormone (FSH) ,and higher-than-normal levels of androgens (male hormones), produced in the ovary.

Insulin resistance also seems to be a key feature in polycystic ovarian syndrome. In addition to other hormones, insulin helps regulate ovarian function. When someone is insulin resistant, this means that cells throughout the body do not readily respond to the insulin circulating in the blood. For this reason, the amount of insulin remains high in the blood (hyperinsulinemia). High levels of insulin can contribute to lack of ovulation, high androgen levels, infertility, and early pregnancy loss.

Polycystic ovaries are two to five times larger than normal ovaries, and they have a white, thick, tough outer covering. Women are usually diagnosed when in their 20s or 30s.

Many women with polycystic ovary disease have irregular periods and may have very little menstruation (oligomenorrhea) or no period at all (amenorrhea).

Women diagnosed with this disorder frequently have a mother or sister with similar symptoms commonly associated with polycystic ovarian syndrome (PCOS).

Conception is often possible with proper surgical or medical treatments. Following conception, pregnancy is usually uneventful.

Symptoms

If you have polycystic ovary disease, you are likely to experience some of the following symptoms:

• Abnormal, irregular, or scanty (very light or infrequent) menstrual periods
• Absent periods , usually (but not always) after having one or more normal menstrual periods during puberty (secondary amenorrhea)
• Weight gain, even obesity
• Insulin resistance and diabetes
• Infertility
• Increased hair growth; distribution of body hair may be in a male pattern
• Virilization -- development of male sex characteristics in a female. This may include an increase in body hair, facial hair, a deepening of the voice, male-pattern baldness, and clitoral enlargement.
• Decreased breast size
• Aggravation of acne

Exams and Tests

In a pelvic examination, the health care provider may note an enlarged clitoris (very rare finding) and enlarged ovaries.

Tests include:

• FSH levels -- low or normal
• LH levels -- generally high
• Androgen (testosterone) levels -- high
• Estrogen (primarily estrone and estradiol) levels -- relatively high
• Urine 17-ketosteroids  -- possibly high
• Vaginal ultrasound and, possibly, abdominal ultrasound
• Abdominal MRI
• Laparoscopy
• Ovarian biopsy

Other blood tests that may be done include:

• Serum HCG (pregnancy test) negative
• Thyroid function tests
• Prolactin levels

Treatment

Medications used to treat the symptoms of polycystic ovary disease include birth control pills, spironolactone, flutamide, and clomiphene citrate. Treatment with clomiphene induces the pituitary gland to produce more FSH, which in turn stimulates maturity and release of the eggs. Occasionally, more potent ovulation-induction medications (fertility drugs, human menopausal gonadotropins) are needed to achieve pregnancy.

Weight reduction, which may be very difficult, may help to reduce the elevated insulin levels in the blood in patients with this disease. For those with polycystic ovaries who are overweight, weight loss can reduce insulin resistance, stimulate ovulation, and improve fertility rates. Sometimes, part of the treatment for polycystic ovaries is use of medications that make cells more sensitive to insulin, like metformin or one of the thiazolidinedione medications.

Outlook (Prognosis)

Pregnancy may be achieved with appropriate treatment.

Possible Complications

• Sterility
• Obesity-related conditions, like high blood pressure and diabetes
• Increased the risk of endometrial cancer -- this is because the endometrium (lining of the uterine wall that sheds when you menstruate) can get thicker and thicker (hyperplasia) due to the lack of ovulation
• Possible increased risk of breast cancer

When to Contact a Medical Professional

Call for an appointment with your health care provider if you are experiencing the symptoms of this disorder.