Cystic Ovaries - Polycystic Ovary Syndrome (PCOS)
The ovaries are the organs that produce the eggs in the female reproductive system. Polycystic ovary syndrome (PCOS) is a syndrome in which the ovaries are enlarged and have several fluid-filled sacs or cysts. These cysts may look like a string of pearls or a pearl necklace. A woman can develop one cyst or many cysts. Polycystic ovaries are usually 1.5 to 3 times larger than normal. Women with PCOS may experience a number of other symptoms as well. PCOS is a leading cause of infertility and is the most common reproductive syndrome in women of childbearing age.
How many women have PCOS?
An estimated five to 10% of women of childbearing age have PCOS (ages 20-40). At least 30% of women have some symptoms of PCOS.
What causes ovarian cysts?
Eggs grow, develop, and mature in the ovaries and then are released during ovulation, part of the monthly menstrual cycle that occurs during the childbearing years. Ovarian cysts are fluid-filled sacs that form on the ovaries when the follicles (sacs) on the ovary that contain the egg mature, but do not release the egg into the fallopian tube where it would be fertilized.
Is it possible to have PCOS without having cysts?
This is an area of disagreement among medical professionals. While most women with PCOS have polycystic ovaries, some doctors will diagnose a woman with PCOS based on other physical symptoms or hormone abnormalities.
What are the other symptoms of PCOS?
Some of the other symptoms of PCOS include:
- Infrequent menstrual periods, no menstrual periods, and/or irregular bleeding;
- Infrequent or no ovulation;
- Increased serum levels of male hormones, such as testosterone;
- Inability to get pregnant within six to 12 months of unprotected sexual intercourse (infertility);
- Pelvic pain that lasts longer than six months;
- Weight gain or obesity;
- Diabetes, over-production of insulin, and inefficient use of insulin in the body;
- Abnormal lipid levels (such as high or low cholesterol levels, and high triglycerides);
- High blood pressure (over 140/90);
- Excess growth of hair on the face, chest, stomach, thumbs, or toes;
- Male-pattern baldness or thinning hair;
- Acne, oily skin, or dandruff;
- Patches of thickened and dark brown or black skin on the neck,
- groin, underarms, or skin folds; and
- Skin tags, or tiny excess flaps of skin in the armpits or neck area.
What causes PCOS?
No one knows the exact cause of PCOS, but studies are looking at whether it is caused by genetics. Also, because many women with PCOS also have diabetes, studies are examining the relationship between PCOS and the body's ability to produce insulin. There is a lot of evidence that high levels of insulin contribute to increased production of androgen, which worsens the symptoms of PCOS. Lastly, the medication valproate, used to treat seizures may cause or worsen the symptoms of PCOS. Switching medications seems to help the condition.
How is PCOS diagnosed?
Diagnosing PCOS involves several steps. Your doctor will take a detailed medical history about your menstrual cycle and reproductive history, including information about methods of birth control and pregnancies. You also will receive a pelvic and physical exam. During a pelvic exam, the doctor is able to feel the swelling of the cysts on your ovary. Once cysts are found, the doctor may perform a vaginal ultrasound, or a screening to examine the cysts and the endometrium (lining of the uterus). If your doctor suspects you have PCOS, he or she may recommend having blood tests to measure hormone levels. Women with PCOS can have high levels of hormones, such as testosterone. Your doctor also may test your insulin and glucose levels, to look for diabetes or insulin resistance (inefficient use of insulin in the body). Many women with PCOS have these conditions. Lastly, your doctor may test your levels of cholesterol and triglycerides since they often are abnormal in women with PCOS. Once your doctor makes a diagnosis, you will work together to decide how to best treat and manage your condition. PCOS can negatively affect fertility since it can prevent ovulation. Some women with PCOS have menstrual periods, but do not ovulate. A woman with PCOS may be able to take fertility drugs, such as Clomid, or injectable fertility medications to induce ovulation. To help ovulation occur, women also can take insulin-sensitizing medications or steroids (to lower androgen levels). Some research also shows that taking low doses of aspirin, which helps prevent blood clotting in the uterine lining and improves blood flow, can improve chances of pregnancy. There appears to be a higher rate of miscarriage in women with PCOS (possibly by 45%). The reason for this is being studied. Elevated levels of leuteinizing hormone, which aids in secretion of progesterone, may play a role. Elevated levels of insulin and glucose may cause problems with development of the embryo. Insulin resistance and late ovulation (after day 16 of the menstrual cycle) also may reduce egg quality, which can lead to miscarriage. The best way to prevent miscarriage in women with PCOS is to normalize hormone levels to improve ovulation, and normalize blood sugar, glucose, and androgen levels. Recently, more doctors are prescribing the drug metformin to help with this.Since PCOS causes high glucose levels, it can be helpful for pregnant women with PCOS to have earlier screenings for gestational diabetes during pregnancy. Gestational diabetes occurs when a woman's ability to process glucose is impaired. The baby also has trouble processing glucose, which can lead to a large baby, immature lungs, and birthing problems. Although a carefully balanced diet and/or insulin injections have been used to control gestational diabetes, there is new evidence that high insulin levels also can be damaging. Some doctors allow pregnant women with PCOS to continue taking metformin in pregnancy, while others won't prescribe it to women trying to conceive. There is no evidence that it causes birth defects, but the long-term effects on the baby are not known. Women and their doctors should discuss the risks and benefits of medications. Women taking medication usually are monitored more closely. After pregnancy, many women with PCOS develop normal menstrual cycles and find it easier to become pregnant again.
Does PCOS put women at risk for other conditions?
Women with PCOS can be at an increased risk for developing several other conditions.
Irregular menstrual periods and the absence of ovulation cause women to produce estrogen, but not progesterone. Without progesterone, which causes the endometrium to shed each month as a menstrual period, the endometrium may grow too much and undergo cell changes. This is a pre-cancerous condition called endometrial hyperplasia. If the thickened endometrium is not treated, over a long period of time it may turn into endometrial cancer. PCOS also is linked to other diseases that occur later in life, such as insulin resistance, Type II diabetes, high cholesterol, hardening of the arteries (atherosclerosis), high blood pressure, and heart disease. Depression or mood swings also are common in women with PCOS. Although more research is needed to find out about this link, there are studies linking depression to diabetes. Therefore, in PCOS, depression may be related to insulin resistance. It also could be a result of the hormonal imbalances and the cosmetic symptoms of the condition. Acne, hair loss, and other symptoms of PCOS can lead to poor self-esteem. Infertility and miscarriages also can be very stressful. Medications that restore the balance to hormone levels or antidepressants can help these feelings.
How is PCOS treated?
Because there is no cure for PCOS, it needs to be managed to prevent further problems. There are many medications to control the symptoms of PCOS. Doctors most commonly prescribe the birth control pill for this purpose. Birth control pills regulate menstruation, reduce androgen levels, and help to clear acne. Your doctor will talk to you about whether the birth control pill is right for you and which kind to take. Other drugs can help with cosmetic problems. There also are drugs available to control blood pressure and cholesterol. Progestins and insulin-sensitizing medications can be taken to induce a menstrual period and restore normal cycles. Eating a balanced diet low in carbohydrates and maintaining a healthy weight can help lessen the symptoms of PCOS. Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and using insulin more efficiently. Although it is not recommended as the first course of treatment, surgery called ovarian drilling is available to treat PCOS. This involves laparoscopy, which is done under general anesthesia on an outpatient basis. A very small incision is made above or below the navel, and a small instrument that acts like a telescope is inserted into the abdomen. During laparoscopy, the doctor then can make punctures in the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. The success rate is less than 50% and there is a risk of developing adhesions or scar tissue on the ovary.