Polycystic ovary syndrome (PCOS)

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome is a common condition that affects millions of women in the UK.*

PCOS is a multisystem condition affecting the ovaries, certain metabolic functions, or the skin, and affects women in their child-bearing years. The exact cause remains unclear, but it is a condition which is associated with increased risks of other health concerns developing in the women that are affected such as diabetes, stroke, fertility difficulty, sleep apnoea and cancer of the womb.

The actual prevalence of PCOS is not known, perhaps due to an under-recognition of the condition, but it is estimated that up to 10% of women in the UK have the condition.

Women who present with this condition often experience a failure to release eggs (no ovulation), and will not be diagnosed with PCOS until they find they are having difficulties trying to conceive. They also have higher levels of male hormones.

What are polycystic ovaries?

Polycystic ovaries become enlarged and develop fluid-filled bubbles just below the surface, and contain eggs that have not fully developed. Most women with polycystic ovaries will not have any problems other than irregular periods. Having polycystic ovaries does not mean you have PCOS.

What is Polycystic Ovarian Syndrome (PCOS)?

Polycystic ovarian syndrome is a name given to a group of problems. In order to have PCOS, you should have two of the following three: polycystic ovaries, an irregular menstrual cycle or an excess of male hormone. The symptoms of PCOS can vary greatly between women and include all of the symptoms listed above.

What causes PCOS?

Polycystic ovary syndrome is associated with hormonal imbalances in the body, although the exact cause is unknown. It’s likely that there is a genetic link, as it tends to run in families (but not always). PCOS women will have higher than normal levels of insulin, which helps to control the level of sugar in the blood. PCOS women will be more likely to be resistant to insulin, so the body produces high amounts of it to overcome this resistance. The high Insulin levels then lead to other hormone problems including high LH (luteinizing hormone) and testosterone. Typically considered a male hormone, all women produce a small amount of testosterone in their ovaries, but the majority of it is usually converted to oestrogen. For women with PCOS, the amount of testosterone produced tends to be higher and this rise in testosterone can affect menstruation and ovulation.

What are the symptoms of PCOS?

Many women with PCOS may have very mild symptoms, so much so that they don’t realise they have the condition until they present with difficulty conceiving.

However, there are still many women who do have symptoms. Those women will have some or all of the symptoms listed below, to different degrees of intensity, depending on the individual. These symptoms include:

• Irregular or no menstrual periods
• Difficulty getting pregnant
• Excessive hair growth (hirsutism) usually on the face, chest, back or buttocks
• Thinning hair and hair loss from the head
• Acne
• Dark skin patches
• Skin tags

If you are concerned about any of these symptoms you should visit your GP for an initial diagnosis. You may be referred to a consultant gynaecologist who can confirm and treat PCOS.

Insulin resistance is a very common feature of PCOS and affects around 75% of all women with PCOS regardless of their weight, but it is an issue which is made worse by an increase in weight. Insulin resistance means that the cells that use glucose as an energy source (muscle, fat and liver cells) do not respond to normal levels of insulin, so the body compensates by producing more insulin which helps the glucose enter the cells. Insulin resistance is a leading cause of developing pre-diabetes, diabetes in pregnancy or type-2 diabetes later in life. In addition, higher levels of Insulin increase the production of androgens from the ovaries which can make the symptoms of PCOS worse.

Symptoms of PCOS often start in the years after puberty into the early 20s. However, women may not be diagnosed with the condition until they present to their doctor with menstrual irregularities, difficulty getting pregnant, acne or excessive hair growth or loss in the areas that men tend to be affected.

How is PCOS diagnosed?

PCOS is diagnosed following investigations and exclusion of other specific conditions. An accepted criterion requires the presence of at least two out of three of the following:

1. Infrequent periods (less than 9 periods a year), or no periods
2. High levels of androgens (testosterone) in blood test or symptoms that suggest higher androgen levels such as excess hair growth on the face or body, loss of hair from the scalp, acne
3. Multiple cysts on the ovaries (more than 12 cysts on one ovary) on an ultrasound scan

Your consultant may order an ultrasound scan to confirm you have polycystic ovaries. They may also order blood tests to check your hormone levels.

How is PCOS treated?

There is no cure for PCOS, but you can manage the symptoms of PCOS. You and your consultant will work on a treatment plan based on your symptoms, your plans for having children, and your risk of long-term health problems such as diabetes and heart disease. Treatments could include:

• Weight loss and lifestyle changes (diet and exercise)
• Medications to balance hormone levels
• Medications to control excess hair and acne
• Fertility medications to stimulate ovulation
• Laparoscopic surgery

Alternative treatment options

Additional treatments include therapies such as acupuncture. Many patients who have irregular cycles with their PCOS have worked with acupuncture practitioners to regulate their cycles. It may not be a treatment for everyone, but is another option that can be explored for treatment.

How to manage PCOS

There are ways to improve symptoms, increase the chances of getting pregnant and decreasing your risk of other health concerns developing.

One of the most recommended routes to mitigate the effects of PCOS is living a healthy lifestyle. Maintaining a healthy weight, eating a balanced diet, not smoking, deceasing your alcohol intake and doing regular exercise will reduce your overall risk of the long-term health concerns associated with PCOS.

Losing as little as 1-2kg of excess body fat can help regulate your cycle, decrease insulin resistance thereby decreasing your insulin and androgen levels, and can improve your chances or getting pregnant.

There are some medications that can help manage the symptoms that occur with PCOS and will depend on whether you are trying to get pregnant or not.

If you are not trying to get pregnant:

• The combined oral contraceptive pill or the progesterone only pill can suppress your ovaries enough to stop the production of androgens. The benefit of the combined pill is that it will provide you with a regular and predictable bleeding pattern, whilst the progesterone only pill may stop you bleeding altogether. Decreasing the amount of androgen produced can improve acne and excess hair growth (especially the combined contraceptive pill)
• A specific pill called Dianette which contains an anti-androgen is very useful to improve acne and excess hair growth, as well as regulate your bleeding pattern. However, this should only be used for a few months before you change over to another contraceptive pill
• If you do not want to, or cannot use hormonal contraception, then your GP may prescribe you a hormonal tablet to take for a few days if your menstrual cycle is very infrequent. This should be taken every 3 months and will make you bleed, keeping your womb lining thin and decreasing the risk of womb cancer occurring
• Metformin is useful to decrease insulin resistance and decrease androgen levels slightly, but it is not licenced for this use. However, many doctors in the UK do prescribe it out of licence in women who have already implemented the lifestyle changes recommended and still have insulin resistance
• Weight loss medications can also improve insulin resistance by decreasing your body fat percentage.

If you are trying to get pregnant:

• Metformin may help you to start ovulating again
• Fertility medications can also be used to stimulate ovulation allowing you to get pregnant.

*Source: NHS Choices