What is Polycystic Ovary Syndrome? (PCOS)

Polycystic Ovary Syndrome, also known as Polycystic Ovarian Syndrome, is an endocrine disorder affecting some women of childbearing age, with one in every ten women experiencing the condition in the UK.

What is Polycystic Ovary Syndrome?

Polycystic Ovarian Syndrome (PCOS) is a condition that impacts the hormonal balance within women. Throughout this article, the abbreviated term PCOS will be used to refer to the syndrome. This is not the same as PCO, which refers to Polycystic Ovaries, which describes multiple cysts in or around the ovaries, without indications that there is an underlying condition.

PCOS specifically affects the ovaries, which are responsible for producing oestrogen and testosterone, as well as the male hormones called androgens. Oestrogen and testosterone are responsible for the menstrual cycle. The ovaries are also responsible for ovulation, which is the monthly release of an egg for fertilisation by sperm from a male; however, the hormones in control of ovulation, follicle-stimulating hormone (FSH) and luteinising hormone (LH), are produced in the pituitary gland in the brain. The FSH triggers an ovary, either the left or right, to produce a follicle, and the LH causes this to mature into an egg.

In someone with PCOS, the ovaries create excess androgens, which set the other reproductive hormones out of balance. The imbalance can cause irregular menstrual cycles, amenorrhea (the absence of periods), and irregular ovulation, or no ovulation at all (anovulation).

The term ‘polycystic’ means ‘many cysts’, as the syndrome usually entails the presence of a number of cysts on the ovaries. These cysts are sacs filled with fluid that develop due to the lack of ovulation. The cysts are follicles that do not mature into eggs. However, you do not need to have cysts to be diagnosed with PCOS, and the cysts are not the root cause of the condition. Similarly, someone may have polycystic ovaries without having PCOS, as PCOS is a combination of different factors, rather than the sole presence of multiple cysts. The cause of PCOS is not clear.

What are the symptoms of Polycystic Ovary Syndrome?

PCOS symptoms can include the following:

• Irregular menstruation or no menstruation (amenorrhea).
• Heavy period flow, including a prolonged menstruation period.
• Hirsutism – This is when women develop thick, excess hair on their body and their face. It usually grows on their neck, chest, abdomen, lower back, thighs and/or buttocks.
• Acne – Acne is common on the face, back or chest as a result of excess production of androgens, which trigger the production of oil.
• Pelvic pain – The pain experienced in the pelvis is thought to be due to the cysts. The pain is often described as sharp and sudden but can also feel achy and prolonged.
• Skin discolouration and pigmentation – This is not a direct result of PCOS but can occur when someone with PCOS develops resistance to insulin. The skin may darken in the underarms or around the neck.
• Enlarged ovaries – One or both of the ovaries can become enlarged due to the excess androgens that cause cysts to form in the ovaries.
• Cysts – The cysts formed in the ovaries in PCOS are usually up to around 8mm in size, and are not harmful, but can be painful. A woman who has polycystic ovaries does not necessarily have PCOS, and must present symptoms of either anovulation/oligoovulation or excess androgens to be diagnosed with the condition.

Other conditions that are associated with PCOS are:

• Type 2 diabetes. Up to 50% of women with PCOS develop this type of diabetes before the age of 40. This is due to the high level of insulin in the body, which gradually causes the body to develop insulin resistance.
• The majority of women with PCOS are overweight or obese, and obesity is in fact a direct catalyst to developing PCOS. PCOS can be described as a metabolic disorder in this sense.
• Sleep disturbance, and most commonly, sleep apnoea, is associated with PCOS, which can cause other symptoms of PCOS to worsen. This is due to the fact that limited sleep impacts the ability to lose weight, thus increasing the chance of insulin resistance and hypertension.
• Endometrial cancer. Women with PCOS can have higher levels of oestrogen, which can heighten the risk of developing endometrial cancer, to almost three times as likely than a woman without PCOS.
• Heart disease. There is a high risk of heart disease in women with PCOS, due to factors such as being overweight, developing insulin resistance and thus diabetes, and being at higher risk for high blood pressure. Women with PCOS may develop heart palpitations. However, there is no significant evidence that PCOS is the root cause of this.
• Stroke. There is a higher risk of stroke in women with PCOS, though again, there is no strong evidence that PCOS is the cause of stroke in women with the condition.

Does PCOS cause infertility?

The question of whether PCOS causes infertility is a complex one, as many women with PCOS successfully become pregnant. However, in women who experience infertility, PCOS is one of the leading causes.

Infertility is when someone cannot conceive. This means that either a woman cannot become pregnant, or a man cannot fertilise an egg. It is a common problem that affects the male and female reproductive system, and is diagnosed when a couple has not been able to conceive within a year or longer.

PCOS affects fertility because it impacts ovulation. This is usually the primary reason fertility is affected in the condition, as the hormonal imbalance causes the ovaries to fail in releasing a mature egg. Thus, there is no egg to be fertilised by the male’s sperm.

Just because infertility affects up to 80% of women with PCOS, it does not mean that they cannot become pregnant. There is still a chance of becoming pregnant, so clinicians encourage women to continue to try. Additionally, if someone with PCOS cannot get pregnant, there may be another underlying condition that may affect their fertility, such as endometriosis. With treatment, many women with PCOS become pregnant.

Couples who are unable to conceive may find success with In Vitro Fertilisation.

What causes Polycystic Ovary Syndrome?

The exact reasons for developing PCOS are unknown. It is believed that many factors are involved:

Genetics

PCOS tends to run in families, with a higher risk for developing the condition if your older female relatives have PCOS. The genetic link has not been discovered yet, but there is substantial evidence to suggest that you are at a higher risk if someone in your family has the condition.

Insulin Resistance

Resistance to insulin is one of the root conditions associated with PCOS, though there is uncertainty as to whether PCOS causes insulin resistance, or the resistance causes the PCOS. Insulin resistance also worsens the symptoms of PCOS, as it contributes to weight gain and heart disease.

How is Polycystic Ovary Syndrome diagnosed?

A diagnosis of PCOS is usually given if the following are present:

Oligoovulation/Anovulation

This may be infrequent ovulation, irregular ovulation, or no ovulation at all. Ovulation normally occurs around two weeks before menstruation commences.

Excess production of Androgens

The normal range of androgens in a woman should be between 6.0 to 86 nanograms per decilitre.

Polycystic Ovaries

Having cysts on the ovaries is normal, and most women develop a cyst on their ovaries during their lifetime. With PCOS, if more than 12 cysts are present at any one time, the ovaries would be considered to be polycystic.

Two of these indicators need to be present to confirm that PCOS is present. Thus, there is no single way to diagnose PCOS, as there isn’t just one test to determine it. Instead, to diagnose PCOS, you need a physical exam, scans and blood tests:

Physical examination

A physical examination includes taking your medical history, and your history of menstruation. The physical examination will look at weight and signs of excess androgens such as hirsutism and acne.

Ultrasounds

One of the main ways that PCOS is diagnosed is through a transvaginal ultrasound. This ultrasound is usually most accurate when carried out in the follicular phase, which is between 2 and 7 days after the last period. The ultrasound provides images of the ovaries, and the clinician will be able to take measurements of the ovaries, which can indicate ovarian enlargement. It also shows how many ovarian follicles are present. To be diagnosed with polycystic ovaries (PCO), there must be more than 12 present, between 2mm and 9mm in size each. This does not necessarily indicate the presence of PCOS.

Blood tests

Blood tests are done to measure hormone levels. Most women who have PCOS, though not all, will have abnormal FSH and LH levels. Usually, FSH and LH levels are at similar levels, between a range of 4 and 8. In women with PCOS, the level of LH is two or three times higher than the level of FSH. The FSH may be in the range of 4 to 8, but the LH can reach levels between 10 and 20. A woman with PCOS may have normal hormone levels, so it is not always an accurate indication. Blood glucose tests and tests for insulin levels may be included.

How to manage Polycystic Ovary Syndrome

There is no cure for PCOS, but there are treatments and lifestyle changes that can help to manage and reduce symptoms. With the ability to control symptoms, women with PCOS live a normal life.

Hormones

As a symptom of PCOS is irregular periods, you may be prescribed birth control pills. Birth control pills that contain both progestin and oestrogen reduce the levels of androgens, and regulate the levels of oestrogen. This helps to lower the risk of endometrial cancer, as well as hirsutism and acne. Alternatively, you may be told to take progestin for half of a month, each month, to help reduce the risk of endometrial cancer and regulate periods.

Ovulation Medication

In the case of anovulation, your doctor may prescribe you the following medications to help the process.

• Gonadotropins.
• Metformin.
• Clomiphene.
• Letrozole.

If the ovulation medication does not trigger ovulation, a surgical procedure called laparoscopic ovarian drilling may be offered. This is keyhole surgery, in which up to six holes are drilled in each one of the ovaries, with the purpose of destroying the thick tissue to reduce the amount of androgens produced.

Medications for hirsutism

There are a number of treatments available to help to reduce excess hair growth:

• Eflornithine.
• Birth control pills.
• Spironolactone (has been known to cause birth defects and shouldn’t be used when trying to conceive).
• Electrolysis. This is when electronic waves are used to destroy the root of the hair (follicle).

Lifestyle changes

Your clinician may recommend lifestyle changes that could help to reduce the symptoms. Regular exercise and changes to diet can help to improve the metabolism and can help to restore insulin function to a certain extent, as diet is directly linked to insulin production and resistance. This may cause ovulation to return. As a part of the diet, reducing sugar and carbohydrates may help to lower the levels of insulin in the body.

A diet consisting of unprocessed foods, with a low glycaemic index, and anti-inflammatory foods can help people with PCOS to manage their symptoms.

Who can support people with PCOS?

• Verity is a UK-based charity dedicated to providing support for those with PCOS. They organise several events and conferences, provide information and support through discussion and social media. They also try to improve the awareness and understanding of PCOS within the healthcare sector in the UK.
• Wellbeing of a Woman is a charity that aims to improve the health and wellbeing of women through research, education and advocacy. They focus on reproductive health specifically.
• Women’s Health Concern provides support, advice and resources regarding many conditions that relate to women, including PCOS.