What is Polycystic Ovarian Syndrome?

Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome, also known as PCOS, is the most common endocrine disorder in women, with a prevalence of up to 10% in the population. PCOS typically presents during the early reproductive years. People who have PCOS have a higher risk of developing metabolic syndromes such as diabetes mellitus, cardiovascular disease, endometrial hyperplasia, and infertility. Furthermore, having obesity may amplify the effects of PCOS. This being said, approximately 20% of women with PCOS do not have obesity. Therefore, identifying PCOS early is especially important. Doing so has the potential to help patients pursue the necessary health screening and medical treatments for the metabolic syndromes associated with PCOS in a timely manner. Furthermore, people with PCOS may encounter difficulty with becoming pregnant, therefore the diagnosis may help guide providers in providing an informed infertility evaluation and treatment options. 

During your evaluation for a diagnosis of PCOS, your doctor will use both clinical and laboratory measures. Blood labs will be done to also ensure that there is not other medical explanation for your symptoms. Your doctor may also perform a transvaginal ultrasound to evaluate the ovaries. 

Etiology

Currently, the genetic cause of PCOS remains unclear, and there is no recommended genetic screening test. No environmental trigger has been identified to cause PCOS. However, research has shown the following to be likely linked to developing PCOS: 

• Insulin resistance: when tissue in the body responds inappropriately to elevated glucose levels in the blood
• Defects of gonadotropic action: abnormal ratio of Luteinizing hormone to follicular-stimulating hormone, which are hormones produced by the ovaries
• Defects of energy regulation
• Defects of steroidogenesis: when there is excess production of androgen hormones by the ovaries and adrenal glands

Diagnostic Criteria

PCOS is a heterogeneous disease, and therefore patients present with a variety of symptoms, with no two people completely alike. The most commonly used guideline for diagnosing PCOS in adults is the Rotterdam criteria. To be diagnosed with PCOS, the patient must have at least 2 of the 3 criteria: (1) Hyperandrogenism (2) Menstrual Dysfunction, and/or (3) Polycystic ovaries by ultrasound diagnosis. 

Hyperandrogenism

Hyperandrogenism can be diagnosed by clinical signs of hirsutism, acne, “male-pattern” hair loss, or blood tests showing higher than normal levels of androgen. Hirsutism presents with thick, pigmented body hair that may be noted in the upper lip, chin, periareolar area, and middle of the chest. It is important to mention here that despite this general description of “hirsutism,” significant variation exists among ethnic groups in hair growth and pattern. East-Asian people with PCOS generally present with a lesser degree of hirsutism than do non-Hispanic whites or African-American people. 

A “positive” blood test for diagnosing hyperandrogenism related to PCOS would show higher than normal levels of total testosterone. However, if the patient has clinical signs of hyperandrogenism, they do not require a blood test for confirmation. 

Menstrual Dysfunction

People with PCOS often present with irregular menstrual cycles.  This pattern of menstruation may either be oligomenorrhea (fewer than 9 menstrual cycles in a year) or amenorrhea (no menstrual period for 3 or more consecutive months). 

However, it has been shown that people with PCOS develop more regular menstrual cycles after the age of 40. 

Polycystic ovaries

To assess the ovaries, a transvaginal ultrasound is used to count the number of follicles in the ovaries. The criteria for having polycystic ovaries is met when in one or both ovaries there are 12 or more follicles seen that are 2 - 9mm in diameter, or the overall size of the ovary is greater than 10cm³. 

Despite the name PCOS containing the term “polycystic ovaries”, not all people with PCOS need to have polycystic ovaries to be diagnosed. 

Management and Treatment

The management of PCOS is tailored toward each patient’s unique clinical presentation as discussed above, in addition to managing the associated metabolic syndromes. Furthermore, patients who may desire a pregnancy benefit from treatments tailored toward treating infertility in people with PCOS. 

1. Lifestyle Modification -  For people who are overweight and obese with PCOS, evidence suggests that lifestyle interventions such as diet, exercise, and behavioral changes improve insulin resistance and hyperandrogenism, in addition to helping with fertility for those who desire pregnancy.
2. Menstrual Dysfunction - The first option for establishing regular menstrual cycles in someone who does not want a pregnancy is starting on a combined oral contraceptive (COC), which contains both estrogen and progestin. Being on a COC also has the added benefit of protecting the endometrium from overproliferation, thus decreasing the risk of endometrial hyperplasia and endometrial cancer. Because of the fewer menstrual cycles in people with PCOS, there is an increased risk of developing endometrial hyperplasia and cancer.
   If a COC cannot be used, there are alternative treatments such as the progestin-only pills “mini-       pill”, levonorgestrel-releasing intrauterine devices, and the medication metformin.

3.  Androgen excess - The medication spironolactone, which is both a diuretic and has anti-

     androgen activity in hair follicles and the ovaries can be used in combination with COC to

     decrease hirsutism (excess hair growth, acne, male-pattern hair loss). Of note, a fully clinical

     effect may take 6 months or more. 

     While medical methods improve hirsutism, it is important to mention that they do not produce   

     complete resolution of symptoms. Treatment is often palliative rather than curative.

To learn more about the management and treatment of Polycystic Ovarian Syndrome contact our

Obstetrics and Gynecology Care Center team who will treat your unique needs.