September is PCOS Awareness Month. Get the facts about this widespread medical condition as we share PCOS resources here and on our Facebook page all this month.
By Mahmood Niaraki, MD
Polycystic Ovarian Syndrome is the most common endocrine problem as well as the most common cause of infertility in women. PCOS overall affects 6.5 to 8 percent of women and the prevalence is 3 to 4 times higher in overweight and obese women. It is important to know that PCOS is a syndrome, not a disease, reflecting multiple potential causes and different clinical manifestations.
This condition has life-long implications with increased incidence of infertility, metabolic syndrome which may lead to Type 2 Diabetes, hypertension, and cardiovascular disease. Patients with PCOS most commonly are insulin resistant and obesity presents in approximately one half of adolescents and adults with this condition.
The two most common clinical presentations of PCOS are irregular menstruation and excessive male hormones. The irregular menstruation is characterized by infrequent or absent periods. Ovulation is also affected by excess male hormones. Pelvic ultrasound usually demonstrates multiple small follicles under 10mm in both ovaries. These follicles may grow and collect fluid, but none may become large enough for ovulation.
When ovulation doesn’t occur, progesterone is not produced. Without progesterone, a women’s cycle will be absent or irregular. In addition severe acne, excess facial hair (hirsutism), hair loss (pattern alopecia) is secondary to excessive male hormones. Some clinical features of PCOS have a familial pattern; several candidate genes have been described but not well proven.
Due to infrequent ovulation and menstrual periods, tissue build up may occur inside the uterine cavity (hyperplasia) which may lead to abnormal bleeding and rarely uterine malignancy.
Also associated with this condition is an increased rate of pregnancy loss as well as complications during pregnancy such as gestational diabetes, and or pregnancy-induced hypertension.
The risks associated with Type 2 Diabetes are mainly being overweight and positive family history and ethnicity. About 40 – 80 percent of children and adolescents with Type 2 Diabetes have at least one affected parent and 85 percent may have first or second degree relatives with this condition.
In general, a low carbohydrate diet and regular exercise can be very effective in improving the signs and symptoms of PCOS, mainly by reducing weight. More important, the medication Metformin may enhance weight loss when associated with a low calorie diet. Metformin may also normalize the menstrual cycles. About 20 percent of the time gastrointestinal side effects may occur with this medication, but the majority of the time it is well tolerated if the dosage is increased gradually or the extended release version of this drug is used. Kidney and liver function studies should be a part of baseline as well as follow up studies.
Depending on whether or not pregnancy is desired, different treatment modalities are utilized in PCOS patients. When pregnancy is desired, Clomid alone, or in combination with Metformin can be utilized. In recent multi-medical center studies it was noted that Clomid is superior to Metformin in achieving as well as maintaining the pregnancy compared with Metformin alone. However, there is an increased rate of twin gestation.
If the above treatment fails, gonadotropin medication can be used to induce ovulation, but the rate of multiple gestation is clearly increased with this type of treatment.
If pregnancy is not desired, oral contraceptives can be used to regulate the cycles. This will also reduce the excessive hair growth and acne by reducing the male hormones originating from the ovaries. The new generation of birth control pills, which contain special diuretics, appear to be more effective to achieve this goal.
In summary, Polycystic Ovarian Syndrome has life long implications with the risk of infertility, metabolic syndrome, Type 2 Diabetes and cardiovascular disease. Therefore,
early diagnosis and treatment of this condition will significantly reduce the complications arising from this common medical condition.
About the Author
Mahmood Niaraki, MD, is a reproductive endocrinologist at Center for Fertility & Reproductive Health at Harvard Vanguard Medical Associates in Burlington, MA.
This article originally appeared in the RESOLVE New England Fall 2008 Newsletter.