What is PCOS?
Polycystic Ovary Syndrome (PCOS) is arguably the most common female hormonal disorder and one of the leading causes of female infertility. It affects about 5 to 10% of women during their reproductive years.
Symptoms and causes of PCOS
Typical symptoms include irregular or absent menstrual cycles, infertility, recurrent pregnancy loss (three or more consecutive miscarriages) and obesity. Then there are also features of elevated androgen levels (the “male” hormones) – such as acne, hirsutism (excessive body/facial hair), and/or alopecia (male-pattern balding).
PCOS can be diagnosed when you have two out of the following three characteristic features:
- Irregular or absent ovulation;
- Elevated androgen levels, which can be detected with blood testing;
- Multiple small “cysts” detected on the ovaries during an ultrasound exam – hence the term “polycystic ovaries”.
Elevated Androgen Levels: Your fertility is adversely affected by excessive androgen (male hormone) production and the depletion of sex-hormone binding globulin (SHBG) – a glycoprotein which usually “mops up” excess circulating androgens. Excess androgens interfere with normal ovulation within the ovary, thereby leading to infertility. However, before you can be conclusively diagnosed with PCOS, medical practitioners have to exclude other less common causes for increased androgen levels (such as hypothyroidism, Cushing’s syndrome, dysfunctional androgen metabolism and adrenal tumours).
Insulin Resistance: Infertility is compounded by other metabolic abnormalities, including “insulin resistance” – a condition in which higher than usual levels of the hormone, insulin, are required to control blood glucose. The excess insulin stimulates the ovaries to produce large amounts of androgens and also increase the conversion of androgens to estrogens, causing the formation of ovarian “cysts”.
Weight Gain: When insulin levels rise, other hormonal changes can also lead to increased appetite and decreased fat burning, which lead to weight gain. This increase in body weight plays an important role in the presentation of PCOS. Women with PCOS typically have an increased upper body – or central – obesity, with associated increased waist-to-hip ratio. This central adipose tissue (body fat) is metabolically active and can add to insulin resistance.
Women who develop PCOS are thought to have a genetic predisposition to PCOS, with the syndrome manifesting when their weight goes above a critical threshold. Frequently, weight gain during pregnancy can lead to the subsequent presentation of PCOS. The genetic predisposition is borne out by the strong familial association. A recent study conducted at Groote Schuur Hospital in Cape Town, determined that 20% of mothers, 45% of sisters and 55% of daughters of women with PCOS had PCOS themselves (Edelstein & Van der Spuy, 2010).
How to manage PCOS
Management depends on your reproductive preferences.
- Pre-family planning: If you don’t want to start a family as yet, then your gynaecologist can help you to control your menstrual and hyperandrogenic symptoms – such as hirsutism – by prescribing an anti-androgenic combined oral contraceptive pill. Hirsutism can also be controlled with specific anti-androgenic medications, including cyproterone-acetate or spironolactone (for hormonal acne), or cosmetic hair removal procedures like electrolysis.
- Ovulation induction: PCOS is linked to anovulation (lack of ovulation), so once it’s been determined that this condition is the sole factor responsible for your infertility (after ruling out blocked fallopian tubes and getting a normal semen analysis from your male partner), treatment can begin with medication to induce ovulation.
For first-line ovulation induction, your fertility specialist may prescribe the anti-oestrogen, Clomiphene Citrate. The biguanide Metformin (a group of hypoglycaemia-inducing drugs) can be used in combination with Clomiphene.
If you don’t respond to the treatment after an adequate trial, other options include using an aromatase inhibitor (such as the fertility medication, Femara) or gonadotrophins (a follicle-stimulating hormone). In the event of lean, hyper-androgenic PCOS, you’ll undergo laparoscopic ovarian drilling (a procedure in which multiple incisions are made into the ovary with a thin needle, in an attempt to reduce the “ovarian cysts”). If standard treatment still doesn’t help you achieve ovulation, you may require in-vitro fertilisation (IVF).
- Lose weight: It’s well documented that obese women with PCOS who reduce their body weight by 10% can resume ovulation without medication. On the other hand, those who don’t lose weight before beginning treatment have a poorer response to ovulation induction. If they do conceive, these women are also at an increased risk of miscarriage. Also, if they manage to conceive and stay pregnant beyond 12 weeks, they’re at an increased risk of pregnancy-related complications such as gestational diabetes (a form of diabetes that develops during pregnancy) and pre-eclampsia (pregnancy-induced high blood pressure). This is why many doctors won’t begin treatment until the patient has lost weight and achieved a Body Mass Index (BMI) of at least <36.
PCOS and metabolic conditions
While women frequently see their gynaecologists complaining of menstrual irregularity, women with PCOS often also have a range of metabolic imbalances. PCOS is a metabolic syndrome and is associated with conditions such as type II Diabetes Mellitus, hypertension and dyslipidaemia (an unfavourable ratio of “good” vs. “bad” cholesterol, that if left untreated leads to cardiovascular disease). These metabolic imbalances have been documented in PCOS women attending Groote Schuur Hospital Gynaecological Endocrinology Clinic. In a study that was conducted over a 10-year period with a group of 885 patients who attended the clinic, obese PCOS patients had significantly more dyslipidaemia and insulin resistance than their normal BMI counterparts (Edelstein & Van der Spuy, 2008).
Apart from taking medication, management of PCOS must include ways to reduce obesity. There also has to be adequate monitoring and screening to see if metabolic complications develop, since these carry the real long-term health risks for patients. As with many other medical conditions, early intervention can prevent long-term complications.
– with thanks to Dr Sascha Edelstein, HART fertility clinic
Dr Sascha Edelstein is a non-executive board member of IFAASA and a Fertility Specialist at the Holistic Assisted Reproduction Clinic in Cape Town.