Diabetes and Lipid Clinic of Alaska



Polycystic Ovarian Syndrome

Polycystic Ovary Syndrome (PCOS) is a common problem in the United States, and is one of the most prevalent endocrine system diseases, affecting as many as 7 to 10 out of 100 (or 7 to 10 percent) of women of childbearing age (15 to 45 years).

An estimated 5 to 7 million women in the United States alone suffer with the effects of Polycystic Ovary Syndrome. PCOS is the most common hormonal disorder among women of reproductive age and is a leading cause of infertility. Even worse, the disorder often goes undiagnosed because of its many baffling and seemingly unrelated symptoms.

While polycystic ovary syndrome was identified almost 80 years ago by Drs. Stein and Leventhal, and is sometimes called the Stein-Leventhal Syndrome, the cause remains unknown. PCOS seems to run in families, and it is likely that it is a genetic disorder. Sisters of polycystic ovary syndrome patients have about a 50% chance of also having PCOS.

Research suggests that many women with this condition may have decreased sensitivity to insulin, called 'insulin resistance.' Insulin, a hormone produced by the pancreas, is necessary to carry sugar from the bloodstream into the cells, where it is converted into energy. When cells are resistant to insulin, it means that the effect of insulin on sugar, and other functions, is deficient. More insulin than normal is required to be produced by the pancreas to ensure that the body cells absorb enough sugar. This leads to high insulin levels in the blood stream which, among other effects, make the ovaries overproduce male hormones, leading to a hormone imbalance that triggers or worsens some of the symptoms of PCOS. Eventually, the pancreas may not be able to maintain the high insulin levels necessary to keep sugar levels normal and the patient develops diabetes

The condition is defined by the presence of hormonal problems, excess hair growth, irregular menstrual cycles and polycystic ovaries, although not all patients have all these features. The term 'polycystic' means 'many cysts' and PCOS gets its name because of the clusters of small, pearl-size cysts in the ovaries. These cysts are fluid-filled bubbles (called follicles) that contain eggs that have not yet been released during ovulation because of the hormonal imbalance.

While the ovaries and adrenal glands of all women release small amounts of 'male hormones,' called androgens, women with PCOS produce levels of these types of hormones in slightly higher amounts. Androgens play a role in helping women grow and develop strong bones and muscles strength, and in sexual function. However, higher levels of this hormone lead to hormone imbalance that can interfere with ovulation and normal egg development. Instead of maturing and being released as usual, each month, the cysts containing the eggs build up in the ovaries. This results in irregular or infrequent ovulation and, in most women, irregular and infrequent menstruation or vaginal bleeding.

Because of the hormone imbalance caused by PCOS, a variety of obvious symptoms can occur. Remember, though, that PCOS is a syndrome, meaning that it is a collection of signs (physical findings) and symptoms (patient complaints), so each person may have a different combination of features than another person. If you have two or more of the following symptoms, you should see your doctor for an accurate diagnosis and a treatment for PCOS that is right for you.

Irregular or absent menstrual periods
Nine or fewer menstrual cycles per year may be a clue that a woman may have PCOS. Bleeding may be heavier than normal.

Women with polycystic ovary syndrome do not form eggs regularly so they may be unable to conceive.

Excess or unwanted body or facial hair growth
PCOS may cause usually fine hairs on a woman's face to become heavier and darker. There may also be increased hair growth on a woman's arms, legs, and elsewhere on her body. Thinning hair on the scalp may be present.

Weight problems
Many women with polycystic ovary syndrome gain weight easily and have difficulty losing extra pounds. Weight gain often is concentrated around the waist. Weight gain is of concern because it puts women at risk for the metabolic problems such as type II diabetes and heart disease. A woman with a waist measurement greater than 35 inches is likely considered to be overweight. Physicians measure waist circumference as a way to estimate a patient's abdominal fat - a predictor of risk factors for obesity-related medical conditions.

Skin problems
-Acne is sometimes found on the face, chest, and back.
-Skin tags, about the size of small raisins, are sometimes found in the armpits or neck.
-Darkening and thickening of the skin may occur around the neck, groin, underarms, or skin folds. This condition is called 'acanthosis nigricans' and often a result of decreased sensitivity to insulin.

In addition to irregular periods and some of the symptoms described above, women with PCOS are at higher risk for a number of serious health conditions. These conditions may go unnoticed, but are potentially dangerous, and include the following:

Diabetes, elevated insulin levels, or insulin resistance
Most women with PCOS have problems using their body's insulin, the hormone that carries sugar from the blood stream into our cells. About 30 percent of women with polycystic ovary syndrome will have some problem with processing blood sugar. This is a major risk factor for adult-onset diabetes, a disease characterized by too much sugar in the bloodstream.

Heart and blood vessel diseases including high blood pressure
Women with PCOS often have elevated levels of the bad cholesterol (LDL), low levels of the good cholesterol (HDL), and high levels of other fats, including triglycerides. These factors are known to increase the risk of heart attack or stroke later in life.

Cancer of the uterus
The lining of the uterus - called the endometrium - normally builds up and is shed with the menstrual period each month. Because of irregular menstrual cycles and lack of ovulation in women with PCOS, the lining of the uterus may not shed as often as is desirable. In this case, the endometrium may become extremely thick. If polycystic ovary syndrome goes untreated, and the lining of the uterus does not shed as it should, this may increase the risk of cancer over time.

Sleep apnea
Characterized by brief interruptions of breath during sleep, sleep apnea is among the most common cause of all sleep disorders, but most people do not know they have it. These breathing irregularities cause snoring and irregular sleep that result in daytime drowsiness, putting people at risk for accidents. Untreated, the problem can be life threatening, putting individuals at increased risk for stroke, heart disease and heart attacks.

The more obvious signs of polycystic ovary syndrome described above are particularly troublesome for women from puberty through their reproductive years. As women approach menopause - the time of life when periods begin to taper off and eventually stop - they may notice that many of their PCOS symptoms diminish in severity. Some women may even begin to experience regular menstrual cycles for the first time. Unfortunately, the risk for diabetes and heart disease increases with age. This means that if you have had symptoms of polycystic ovary syndrome for most of your life, then you should be carefully evaluated for diabetes, insulin resistance, and heart disease, even if you’re overall symptoms are improving with age.

PCOS Treatment Options
Once you are correctly diagnosed, you can begin any of a number of treatments for PCOS depending on the specific symptoms you are experiencing, your age, and your plans regarding pregnancy. Some treatments can relieve distinct symptoms such as acne and weight gain, for example. Other treatments can help to put your body back into balance with the proper amounts of hormones.

The following options for treatment for PCOS have helped many women:

Birth control pills, or oral contraceptives, contain female hormones that help to regulate menstrual cycles. Contraceptives also help to lower levels of androgens, reducing abnormal hair growth and improving acne.

Insulin-sensitizing medications used to treat adult-onset diabetes are useful for many women with PCOS. While these medications have not been approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of PCOS, they seem to improve the regularity of menstrual cycles by lowering insulin levels. Metformin is the most commonly used drug, but doctors should prescribe it with caution. There is not enough research at this time to recommend this drug for all women with PCOS.

Ovulation Induction
In some women who wish to become pregnant, inducing ovulation, which is the release of an egg, is necessary. In current methods of reproductive endocrinology, the initial treatment to induce ovulation is usually an oral medication called clomiphene citrate, which is taken for five days. If clomiphene is not effective, the next order of treatment often includes an injection of gonadotropins. Gonadotropins are hormones that the body produces to stimulate ovulation.

Other infertility treatments may include additional medications or laparoscopic surgery. High-tech treatments include in-vitro fertilization, in which an egg fertilized with sperm is implanted in the uterus.

The insulin sensitizer metformin appears to be helpful in inducing ovulation and conception in some patients, but it is generally less effective than clomiphene or gonadotropins in inducing pregnancy. Metformin appears to work better in normal weight, rather than obese PCOS patients. At this time there is no consensus on its safety if also used during pregnancy.

Androgen-blocking (anti-androgen) medications can be used to treat several PCOS symptoms, including excess or unwanted hair growth and, to a limited degree, acne and scalp hair loss. Spironolactone, flutamide and finasteride can help to relieve the symptoms of excessive facial and bodily hair, as well as thinning hair on the scalp and acne. These medications can be taken along with oral contraceptives. Note that although there is extensive worldwide experience with their use in PCOS, none of these medications have been approved for use in the treatment for PCOS by the FDA.

Topical anti-hair-growth medications also can help to slow the growth of facial hair in women with PCOS, specifically a lotion containing eflornithine hydrochloride. The active ingredient in this medication blocks an enzyme found in the hair follicle of the skin needed for hair growth. This results in slower hair growth within a few weeks of treatment. This medication is FDA-approved for use on the face only

Other methods of treatment for excess hair caused by PCOS include bleaching, depilatory creams, and shaving excess hair. These treatments are safe and easy approaches, although waxing and tweezing, particularly of sensitive skin areas are discouraged, as they can damage the skin. Electrolysis and laser treatments to remove hair also can be effective.

Acne treatments sold over the counter also can help to control the skin blemishes related to polycystic ovary syndrome, although some patients may require additional medications, such as isotretinoin.

Skin problems other than acne may be treated in different ways. You can ask your doctor or dermatologist to remove skin tags using just a simple anesthetic on your skin. The dark blemishes on your skin may fade if you can reduce your insulin level by weight loss or through the use of insulin-sensitizer medications. Other treatments include tretinoin gel, 15% urea, alpha hydroxy acid, and salicylic acid.

PCOS Lifestyle and Prevention
If you have been having irregular periods and some of the other symptoms of polycystic ovary syndrome, please see your family doctor or an endocrinologist. Having infrequent periods is not just a nuisance; it can lead to complications like cancer of the uterus. Early treatment of PCOS can contribute to your long-term health and well being, and improve your quality of life. Polycystic ovary syndrome appears to be an inherited condition. If your mother or sister has PCOS, you may want to be checked for the syndrome. Monitoring your health is important if you have been diagnosed with PCOS.

If you are overweight, for example, you should have a test to check for your risk of diabetes. The routine fasting blood glucose test is inadequate to diagnose diabetes in all women with PCOS. Instead, the oral glucose tolerance test is considered the "gold standard" as a sensitive tool to assess your risk. This test requires several hours of monitoring your response to sugar.

Because of the possible increased risk of cardiovascular disease in women with PCOS, you should have your blood pressure checked regularly. You should also monitor your levels of bad cholesterol (LDL), good cholesterol (HDL), and triglyceride levels. Vigilance is key if you are overweight.

Staying as healthy as possible is the goal. Try to stay on a healthy diet with adequate amounts of protein, as well as whole grains and lots of fruits and vegetables. Your doctor should be able to suggest a healthy diet to follow.

Some women with PCOS find success by reducing their total intake of refined carbohydrates (sugars and starches) and replacing them with complex carbohydrates (fruits and vegetables). Refined carbohydrates include white flour foods such as cereals, breads, and pastas. Complex carbohydrates, in comparison, are less processed foods such as those prepared with stone ground whole-wheat flour. Replacing manufactured white-flour foods with a wide variety of whole grains, fruits, and vegetables can help to reduce your insulin response. Your diet should also include enough protein to control the amount of sugar in your blood.

Exercise helps the body use insulin more effectively and is highly recommended as well. It helps with weight loss and keeping off weight. Many scientific studies have shown that exercising for at least 30 minutes a day, about five days a week, is highly beneficial to your health.

Exercise regularly to keep your weight in check, improve your body's response to extra insulin, and reduce your risk of diabetes, heart disease, and stroke.

Finally, be sure to find a physician who will listen to you and answer your questions. Women with polycystic ovary syndrome sometimes have special concerns about their appearance that are directly tied to their condition. You and your doctor must act as partners to manage all aspects of this complex condition.

With proper diagnosis and treatment, most PCOS symptoms can be reversed or at least managed and your risk of complications greatly minimized.

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