Polycystic Ovary Syndrome (PCOS)
Friday, November 10, 2006
Carl M. Herbert, MD
The various symptoms of PCOS can be irregular or absent menstrual cycles, infrequent or absent ovulation, excess facial and body hair, male pattern balding, acne of face/back/chest, and infertility. Other findings can include an elevated FSH to LH hormone ratio, elevated levels of male hormones, multiple small cysts of the ovaries and elevated cholesterol.
Some women with PCOS also suffer from other subtle endocrine abnormalities. One is insulin resistance, which affects sugar and fat metabolism, and may increase the long-term risks of heart disease, diabetes and high cholesterol. Insulin resistance (IR), the precursor state to diabetes, is present in 35-40% of women with PCOS, even if they are not overweight. Insulin resistance is diagnosed by blood testing, either as fasting glucose to insulin ratio, or as a complete glucose tolerance test (GTT). Long term follow up of women with PCOS reveals that up to 40% develop impaired glucose processing or diabetes by age 40. The prevalence of diabetes in women with PCOS is seven times higher than for the non-PCOS population. Excessive insulin production is thought to promote excess male hormone production, though the actual mechanism explaining this observation is still unclear.
The causes of PCOS are unknown. We do know that the imbalance of the ovarian hormones exists, which prevents the eggs from growing and ovulating every month. Additionally, this imbalance contributes to an excess of male hormone production by the ovaries, which can be worsened by insulin resistance. There is no cure for PCOS, though the various symptoms can be addressed and managed, and therefore help reduce the risk of long-term health consequences.
Numerous strategies are available for women with PCOS wishing to achieve pregnancy.
For overweight women, simply loosing 10-15% of total weight may be enough to allow spontaneous ovulation to occur. If so, then fertility medications would not be needed.
If fertility medications are required, the first and simplest step is to use the fertility pill Clomid (Clomiphene Citrate). We typically start treatment with the lowest dose (50 mg/day), and once a dose which achieves ovulation is determined, we remain on this dose for future cycles.
If ovulation is not achieved using a dose of 200 mg/day, then other strategies have to be investigated. These strategies include using injectable medications (gonadotropins), which are administered using a "low-slow" protocol. When using injectable medications we must be careful to use enough mediation to have one or two eggs grow, but not so much medication that too many eggs grow. This strategy of using low doses of medications, with slow increments in dosage increase, describe the "low-slow" protocol.
If this strategy proves ineffective, then pursuing in vitro fertilization (IVF) is the next treatment option.
In 1935, Stein and Leventhal originally described the syndrome we now call PCOS. Their strategy for treatment was to surgically reduce the size of the ovaries by performing a "wedge resection" (removing a wedge of ovarian tissue). This procedure would result in a decrease in male hormone production by the ovaries, and would allow approximately 80% of the patients to ovulate. Today, we can surgically perform a similar operation called "ovarian cautery or drilling", which is performed by laparoscopy. This procedure is a treatment option for women who fail medications (Clomid or gonadotropins), and who may not want to pursue other available options. Ovarian cautery provides approximately an 80% chance of spontaneous ovulation. Patients who are not spontaneously ovulatory may be more Clomid "sensitive". Therefore, resuming Clomid therapy may now provide ovulatory cycles.
For patients diagnosed with insulin resistance, there is another treatment strategy. Insulin-sensitizing medications can be used to decrease insulin levels, which may help restore the normal ovarian hormone profile (i.e. reduce male hormone), thus allowing for spontaneous ovulation to occur in about 75% of patients. The most commonly used medication is Metformin (Glucophage). There are newer insulin-sensitizing medications available, though these have not been studied extensively in PCOS patients (rosiglitazone maleate (Avantia), pioglitazone hydrochloride (Actos)). Studies with Metformin indicate that most women with PCOS and IR will spontaneous ovulate after 3 months of treatment, or if not ovulatory, will become Clomid "sensitive". One must be carefully screened prior to a course of Metformin, and must be monitored during treatment. Side effects are mostly gastrointestinal (nausea, vomiting, diarrhea).
As with any endocrinologic disorder, patients need a full and complete workup with a physician experienced in that particular disorder. Your reproductive endocrinologist will review old medical records and may ask you to have additional testing. Once all of this information is available, and once a full infertility evaluation is completed (eg. semen analysis, hysterosalpingogram as needed), then treatment options can be reviewed. When you and your partner have decided on the best initial plan, a fertility specialist can proceed with treatment.
15 Comments:
At Fri May 11, 01:19:00 AM 2007,
Anonymous said…
i am 22 years old and found out a week ago that i have polycystic ovaries. i still am quite unsure about what it is or what to do and i am really quite upset that maybe cannot have children as 3 years ago i regrettably had a termination. this is all so new and scary and i think i am giving up hope. i just hope one day it all works out for the best.
At Wed May 16, 05:43:00 PM 2007,
Carl M. Herbert, MD said…
Dear Anonymous,
Please reread our information on PCOS. It is very common! As you should have all your questions answered properly and, if needed, a treatment plan which addresses your situation provided, I suggest you find a reproductive endocrinologist (RE) in your area for a consultation. REs are all OB/Gyns who have special training in these kinds of problems and can give you the best information. Usually someone with PCOS does not ovulate (or menstruate)regularly and therefore may have trouble getting pregnant for that reason. This problem can easily be addressed and success rates are quite good especially in young women like yourself. Your previous pregnancy is proof of that and the termination should have no impact on future pregnancies. Don't be scared as this is a very managable condition. Simply find the right doctor and get the right information. You can get some information at the following website:
http://www.asrm.org/Patients/patientbooklets/hirsutismPCOS.pdf
which is a pamphlet published by the American Society of Reproductive Medicine. You are going to be ok.
Dr. Carl M. Herbert
At Mon May 21, 07:17:00 PM 2007,
Anonymous said…
Hi I am 21 yrs old and have been living with polycystic ovarian syndrome for the past 3 yrs and me and my husband are wanting to have a baby and I just have a hard time wanting to take Metformin does this medication make your blood sugar drop.....
At Tue May 22, 03:23:00 PM 2007,
Carl M. Herbert, MD said…
Dear Anonymous,
The most common problem with PCOS relative to fertility is decreaesd ovulation. Therefore, many women who are diagnosed with PCOS will need medications to help them ovulate in a predictble pattern which allows for proper exposure and a reasonable chance of conception. It was originally thought that Metformin would either induce ovulation by itself or improve ovulation when using clomid. Metformin works by increasing the body's ability to use glucose thus lowering the blood level of insulin. High blood levels of insulin were thought to interfere with normal ovarian functions such as ovulation. Therefore, by lowering the blood insulin levels, these functions are expected to improve. In diabetics metformin has been shown to decrrease the blood sugar level while decreasing the amount of insulin needed. Diabetics have higher blood sugar levels to start, so lowering the blood sugar levels would be sen as a good thing. It does not appear that PCOS women taking metformin become "hypoglycemic" (low blood sugar levels) so I don't think you need to worry about low blood sugar. However, there have recently been a couple of good scientific research papers published which do not show definite benefits for PCOS women taking metformin. See The New England Jounal of Medicine, Volume 356, Number 6, pages 551-566. The pregnancy rates and the miscarriage rates in these studies did not seem to be any different whether the patients were on Metformin or not. Therefore, I think there is some question as to the true benefit of metformin for PCOS patients. Perhaps there are certain patients, maybe ones with elevated insulin levels, who will still show benefit. However, for now, if you are uncomfortable taking metformin, its probably OK to proceed with trying to conceive without it.
Dr. Carl M. Herbert
At Wed May 30, 11:26:00 PM 2007,
Anonymous said…
Hi,
I am 27 yrs old and married for last two yrs. I have been having irregular periods from begining. I recently took all the tests and doctor suggested me (Clomiphene Citrate)to ovulate regularly and conceive as well. I took the lowest does (50mg) and ovulated also for two cycles but did not conceive. Ultrasound scan showed good response to (Clomiphene Citrate). The follicles were just growing in size and were not breaking naturally. It grew more than 33mm. So i had to take HCG 10,000 Injection to induce follicular rupture. Inspite doing all this i did not conceive. Then the doctor suggested me to go for higher dosage of (Clomiphene Citrate) which i am not quite happy about since i showed good response for 50mg itself.
Please suggest what can be done next. I am desparate to conceive.
Thanks
Priya
At Fri Jun 01, 11:53:00 PM 2007,
Pratiksha said…
I am 22 not yet married i am overweight have this poblem is there any way to ovulate without taking any medication as I will be getting married this year and wants to concevive in future as per doctor she wants me to take 1 tablet for rest of my time could you please advice if something can be done ? if by reducing weight my problem will be solved ? I really do not want to get adicted to any medication.
At Tue Jun 12, 08:09:00 AM 2007,
Thomas said…
Hi, my wife and I have a 4 year old and a 18month old. We had no difficulty getting pregnant with either. She has Polycystic Ovaries but this didn't cause a problem. We have been using the test kits to get the right days which worked the last time. We have been trying now for 6 months with no success. My wife is 35 and I am 33. Could it be that the syndrome has now kicked in?
Take care,
thomas
At Thu Jun 21, 02:49:00 PM 2007,
Anonymous said…
Hello...I am 25 yrs old and have 4 children...well at not having any problems gettign pregnant with my 4 children I wanted to help a friend whos wife can not have children...and when I went for the doctors visit for an ultrasound to diganose ovulation I was told by the doctor that I have Polycystic Ovaries..Is this something that can just develope or do you have to have it all your life and then it starts affecting you...I have had a few problems the last few years that I never realted with something like this as I had no problems getting pregnant 4 times. I have gained a significant amount of weight in the last 3 or 4 years. What is the best way for me to treat this ....
At Tue Sep 11, 02:12:00 PM 2007,
nicole said…
I am 24 years old and after a year of trying to concieve with no luck, i visited my gynocologist. I had a sonogram and my doctor called to advise I had polcystyc ovaries and that I was not ovulating. I have since had bloodwork tests, an HSG test and a postcoital test. i am now even more confused than ever. i just visited my doctor again who said my bloodwork showed good levels of progesterone and that yes i am ovulating. how can this be? if i have polycystic ovaries. i am just at a loss and my doctor doesn't seem to want to answer my questions.
At Tue Oct 16, 04:52:00 PM 2007,
Anonymous said…
I am 24 years old and stopped menstrating about a year ago. My doctor concluded with lots of tests that I am not ovulating. I am overweight, and have terrible cholesterol, even with moderate exercise and diet. I have been unable to lose any weight. Even though I am not insulin resistant, and my labs are perfectly normal, except for a lack of progeserone, the doctor insisted putting me on Glucophage! Should I insist on clomed
At Thu Nov 29, 07:29:00 AM 2007,
Anonymous said…
I am 40 and was diagnosed with PCOS 3 yrs. ago. Hubby and I tried for a baby, but now we are putting off having children until I get myself on the right track with this problem... Some history: Since I was a teen, never had a regular cycle (my then OB-GYN dismissed this,"some women are just irregular nothing to worry about.") I have always been at least 15 lbs. overweight, and still get acne if I am not on Mircette (the only bcp I can tolerate). I have exercised regularly, 3-4xs a week for the past 15 yrs. (spinning, step aerobics, power yoga, weight lifting) and can NEVER lose weight, esp. around my middle. Went to Jenny Craig--lost 9 pounds, but gained it back again. Went to WW a couple of times years ago, but the weight crept back on. I eat very healthy, but sometimes fall victim to carb cravings after workouts.
Went to an endo. and he basically said the bcp is the only treatment for pcos. That answer wasn't good enough for me. Found a REPRODUCTIVE endocrionologist, got more labs done and noticed my insulin was high, AND my cholesterol is starting to rise (from 159 3 yrs. ago to over 200 currently!) Was put on Glucophage XR. Experienced AE: cold hands/feet and muscular pain in both legs. After only 6 days on it doc took me off of Gluco. She has not explained to me what the AE was, so I tried researching it myself. Is it low blood sugar? I did NOT have much of an appetite, no carb cravings, and was constantly thirsty... Were my muscle aches from lactic acidosis? Liking my red wine made me a little curious about this dangerous side effect. I drink on weekends and will have maybe 3-4 glasses of wine within a 4-5 hour period (that's a heavy night for me!) Should someone who ingests a few cocktails on the weekend or with dinner be overly concerned with this?
Also, since I cannot tolerate the Glucophage is there another med. I can take for my insulin?
I apologize for the long message, but there is so much I am still not sure of with this disease...
Any help would be greatly appreciated!
D.
At Thu Nov 29, 11:48:00 AM 2007,
Anonymous said…
I am 28 years old and have recently been diagnosed and treated for PCOS.I had started to take meds for a IVF cycle but had to stop in the middle because I was having a side effect.I recently had Ovarian drilling and was wondering if this could possibly help me to ovulate.I can not afford to pay to try another cycle because of cost of meds. Can you please help me to get some answers
At Fri Nov 30, 12:14:00 PM 2007,
Anonymous said…
I am 32 yrs old and about to enter my fourth year of trying to conceive. I terminated a pregnancy in 2000, experienced a chemical pregnancy in 2006, and suffered a miscarriage resulting in a D&E in 2007. I've had almost every test known to man - HSG, endometrial biopsy, laprascopy, sonohistogram - and two trials of 50mg/day for 5 days of Clomid. Each time resulting in large cysts that go away naturally. I've also had an HSG shot. I am now with a RE who is leaning towards classifying me with PCOS. My last cycle of Clomid resulted in 4 mature eggs and my doctor prematurely deemed me pregnant but I started to menstruate 3 days later. I am so frustrated and ready to stop doing anything. I even went to a nutrionist who specializes in Contact Reflexology Technique and was taking herbal supplements for my gallbladder, thyroid, and hypothalamus and to curtail my sugar cravings. Where do I go from here? Is it time to consider adoption??
At Sun Dec 09, 07:51:00 PM 2007,
Anonymous said…
i am 28 years old and have some questions regarding ovary cyst, the doctor has informed me that i have a solid mass in the size of 4cm on my right ovary and should have the ovary removed my afraid that after i have the ovary removed i will not be able to have children, we have been trying but would like to know if i should have this removed before i continue or wait until after i get pregnant and have the baby?
At Fri Jan 11, 05:28:00 PM 2008,
Anonymous said…
I am 13 years old and found out today that i have PCOS.The first thing I did was run to the computer and research it. The most horrifing fact was that i probaly can not have children( in the near future ). I dont know how to react to it and truth ne told i am scared.
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