What is the polycystic ovaries syndrome?

The polycystic ovaries syndrome (PCOS) is a condition that affects the way the woman’s ovaries function. It is a quite common condition and, in fact, it is the commonest endocrine disease of reproductive age women.

According to the latest scientific consensus, the three main PCOS features include:

1. the appearance of many, small cysts in the ovaries (polycystic ovaries).
2. ovulation iregularity (the ovum- egg, is not released from the ovary in the normal frequency).
3. ‘male’ hormones (like testosterone) levels increase, or signs of increased levels of these hormones.

In order to diagnose PCOS, two out of three of the above features need to be present.

What is the difference betweek polycystic ovaries and polycystic ovaries syndrome?

Polycystic ovaries are called the ovaries that have many, small cysts. But, according to the current definition, in order to diagnose the polycystic ovaries syndrome, two out of three of the above mentioned features need to be present (see above). That means that some women with polycystic ovaries will be included in the syndrome definition (if they have at least another finding), but women that ONLY have polycystic ovaries (and no other feature) are not considered to suffer from the syndrome and management should be entirely different.

What are the PCOS symptoms and signs?

The PCOS symptoms usually appear at the late teen years or at the beginning of the twenties. Symptoms may include some of the following:

• irregular periods or absence of periods
• difficulty getting pregnant (because of irregular ovulation or total absence of ovulation).
• excessive hair growth, usually on the face, chest, back, buttocks.
• weight gain.
• thinning hair and hair loss from the head.
• oily skin or acne.

How are fertility problems explained in women with PCOS?

PCOS is one of the leading causes of female sub- fertility. In fact, many women first discovered they have PCOS after investigation due to difficulties getting pregnant.

In every cycle, ovaries release one egg into the uterus. This process is called ovulation and usually happens once a month.

However, in women with PCOS ovaries fail to release the egg entirely, or release it in irregular intervals, therefore women have irregular periods or no period at all and, as a consequence, find it difficult to get pregnant.

Are there any long- term health consequences from PCOS?

Having untreated PCOS for a long time can increase your chances of developing other health problems later in your life. For example, women with PCOS are at increased risk of developing:

• diabetes mellitus type 2, a chronic condition where the blood sugar levels are abnormally high.
• increased blood pressure and increased cholesterol levels, that can lead to heart disease and stroke.
• depression and mood swings, because PCOS symptoms can negatively affect your self- confidence and self- esteem.
• sleep apnea, in obese women this sleep disorder, that causes interrupted breathing during sleep, can develop.
• endometrial cancer. In women that had no periods for a long time or had less than three to four periods every year, had increased risk than the others to develop endometrial (the inner lining of the womb) cancer later in their life. Even so, the chance is very low and can be further minimised with the right treatment that can make periods regular.

What are the causes of PCOS?

The exact PCOS causes are unknown but it is common for PCOS to run in families, although this is not always the case. The syndrome is usually associated with an imbalance in the levels of some hormones, amongst which increased insulin levels.

• Insulin resistance

Insulin is a hormone that is secreted by the pancreas and regulates blood sugar levels. Insulin helps cells ‘consume’ the blood sugar. Many women with PCOS exhibit resistance of their body in the insulin action. That means that their body has to produce increased amnounts of insulin to compensate for this resistance.

The higher levels of insulin make ovaries produce increased amounts of the so called ‘male’ hormones’, like testosterone. Testosterone inhibits the follicular growth and therefore stops the normal release of the egg from the ovary.

The insulin high levels can increase the body weight and the increased body weight can, in turn, cause further increase in the amount of insulin secreted by the body, thus causing a vicious cycle.

• Hormonal imbalance

In many women with PCOS there are several hormonos that are deregulated, such as:

• increased levels of testosterone, a hormone that despite being considered as male, is normally produced in small quantities from women, too.
• ιncreased levels of the luteinising hormone (LH), a hormone that induces ovulation, but in increased levels it suppresses it.
• decreased levels of the sex hormone binding globulin (SHBG), a hormone that binds with testosterone and limits its action.
• increased levels of prolactin (only in somewomen with PCOS), a hormone that stimulates the breast to produce milk during pregnancy.
• Genetics

Studies show that PCOS runs into families. Therefore, if your mother, sister or aunt has PCOS, then the chance you will develop PCOS is higher. That means that there should be some genes involved but which ones are exactly associated with PCOS is still unknown.

What is the treatment of PCOS?

There is no definite treatment to cure the syndrome but symptoms can be managed. There are several treatment options that need to be individualised to each woman’s presenting symptoms.

• Change of lifestyle

The first and very important step in treating PCOS in case you are overweight, is to try to lose weight, exercise frequently and eat healthy. Many times, losing as little as 5% of the body weight can vastly improve symptoms and restore normal periods.

• Medications

There are several pharmaceutical ways to treat the different PCOS symptoms. The choice should be individualised according to each woman’s need. The various options are described below:

Irregular periods or no periods at all

The combined oral contraceptive pill can help regulate the period otherwise we can administer progesterone tablets to induce periods if no period has come for more than three months.

This way, we will reduce the related to the prolonged absence of periods risk for endometrial cancer. In some women, an intrauterine (IUS) system will also reduce this risk, but won’t cause periods.

Fertility problems

With the right treatment, most women with PCOS can conceive. A medication called clomiphene is, usually, the first line treatment for women with PCOS who want to get pregnant. Clomiphene can induce the egg release from the ovaries.

In case clomiphene is not effective, adding another medication called metformine was found to be useful. Metformine can reduce the insulin and blood sugar levels in women with PCOS. Apart from inducing ovulation, metformine can help restore regular periods, reduce the miscarriage risk, but even reduce the cholesterol levels and reduce the heart disease risk. Therefore, metformine is useful not only to women with PCOS that are trying to get pregnant but also to those that pregnancy is not their first priority.

If you cannot stay pregnant with the combination of clomiphene/ metformine then we should use another category of medications, called gonadotrophins, to stimulate ovaries.

In the rare event that no medical method works, there is a surgical procedure that is done laparoscopically and aims at improving the ovarian environment. This procedure is done very rarely, nowadays, since the medical methods have proven to be very efficient.

Unwanted hair growth and hair loss

In case unwanted growth (or hair loss) is a serious concern then there are pharmaceutical methods to improve symptoms.

• particular types of combined oral contraceptives with the minimum androgenic effect
• cyproterone acetate
• spironolactone
• flutamide
• finasteride

This medications work by blocking the effect of ‘male’ hormones, like testosterone and some may also reduce their production by the ovaries.

A cream with eflornithine can also be used to slow down the growth of unwanted facial hair, although results are not guaranteed and it takes some weeks for effects to appear.

All the above mentioned methods do not remove hair or cure unwanted facial hair, so you may wish to use it alongside a hair-removal method. Such methods are plucking, shaving, threading, creams or laser removal.

Other symptoms

There are medications we can add aiming at specific symptoms that insist, such as:

• weight-loss medication, such as orlistat, if you’re overweight
• cholesterol-lowering medication (statins), if you have high levels of cholesterol in your blood
• acne treatments

Surgical treatment

A minor surgical procedure called laparoscopic ovarian drilling (LOD) may be a treatment option for fertility problems associated with PCOS.

Under general anesthesia, we will make three small cuts in your lower abdomen (tummy) and pass a long, thin microscope called a laparoscope through into your abdomen. The ovaries will then be surgically treated using heat or a laser to destroy the tissue that’s producing androgens (male hormones).

LOD has been found to lower levels of testosterone and luteinising hormone (LH) and raise levels of follicle-stimulating hormone (FSH). This corrects your hormone imbalance and can restore the normal function of your ovaries. Nowadays, this procedure is rarely performed as the medical treatment methods are very effective.

Are there any risks during pregnancy for women with PCOS?

If you have PCOS, you have a higher risk of pregnancy complications, such as high blood pressure (hypertension), pre-eclampsia, gestational diabetes and miscarriage. These risks are higher if you’re obese. Therefore, pregnancy follow- up should be adjusted accordingly and by losing weight before trying for a baby is beneficial.