Polycystic ovary syndrome

What is it?

Estrogen and progesterone are the female hormones produced by the ovaries. The levels of these hormones vary during the monthly menstrual cycle. They are essential to the development of follicles, which are fluid-filled pockets, containing an egg that is released each month.

A third hormone, testosterone, also is produced by the ovaries in small amounts. Testosterone is in a broad class of hormones called androgens, and it is the dominant sex hormone in men. Between 4% and 7% of women produce too much testosterone in their ovaries. These women have a pattern of symptoms called polycystic ovary syndrome.

When a woman has a high level of androgen hormones such as testosterone in her body, she can be unable to release eggs from their follicles in the ovaries. Since the fluid-filled follicles don't open and empty, they stay in the ovary and the ovaries appear to contain multiple small cysts. This is the reason for the term "polycystic" in the name of the disease. Women with this condition may have problems with fertility because egg release (ovulation) stops or happens only once in a while.

In addition to the problem of egg release during a monthly cycle, the woman's hormones don't change levels as they normally should. In reaction, the uterus manufactures a fragile inside lining that can cause her to have irregular bleeding. The lining is not shed all at once as during a normal menstrual period. Because of the abnormal hormone balance, the lining of the uterus is also at a higher risk of developing a cancer.

In women with polycystic ovary syndrome, the androgen hormones also cause cosmetic effects. Women with high levels of androgens can have acne and can have increased hair growth in a male pattern such as in the mustache area or on the face.

Commonly, women with polycystic ovary syndrome not only have high levels of androgen hormones. They also have high levels of insulin and resistance to insulin's effects. The high insulin levels are a marker for other health concerns that occur with this disease.

As is true for anyone with high insulin levels, women with polycystic ovaries are more likely to become obese. And they are at a higher risk of developing diabetes, high blood pressure, and heart disease.

Excess insulin may trigger the ovaries to make extra androgen hormones. So insulin resistance — a change in how efficiently you metabolize food calories — may be a trigger for polycystic ovary syndrome in some women. However, experts are not sure that insulin is always the root of the problem.

Genetics and the way that some of the body's glands are programmed (the ovaries, the pituitary gland, and the adrenal gland) also play a role in causing this condition.

Symptoms

Polycystic ovary syndrome usually does not cause symptoms before mid-puberty, when the ovaries begin to produce hormones in significant amounts. Women then can have some or all of the following symptoms:

• Menstrual periods that are infrequent, irregular or absent
• Difficulty getting pregnant
• Obesity (in 40% to 50% of women with this condition)
• Acne
• Hair growth in the beard area, upper lip, sideburns, chest, the area around nipples or the lower abdomen along the midline
• Darkened, thickened skin, sometimes appearing similar to velvet, in the armpits.

Diagnosis

If your periods are irregular, a pregnancy test should be done.

Changes in the growth pattern of your hair or the development of acne may be enough for your doctor to determine that you have a high level of androgens, such as testosterone. If not, blood tests can detect high androgen levels.

A blood test may also be used to check the level of prolactin, which is a hormone produced in the brain's pituitary gland. Very high prolactin levels can be caused by a pituitary gland tumor, and this problem can cause symptoms that resemble those of polycystic ovary syndrome.

As long as other causes of your symptoms have been excluded, your doctor will diagnose polycystic ovary syndrome if a blood test shows a high testosterone level and you are having infrequent or absent menstrual periods. Testosterone can't be tested reliably if you are currently taking birth control pills. Your doctor is likely to check the levels of other hormones that can be associated with high testosterone or can cause similar symptoms, to be more certain about your diagnosis.

Your doctor may choose to look at your ovaries using ultrasound, especially if the ovaries feel enlarged during your pelvic examination. An ultrasound test is likely to show multiple cysts in the ovary. The test also can be misleading. Some women have all the typical hormone abnormalities of this condition, but their ovaries have not developed cysts. The diagnosis and treatment for these women is no different.

Because of the increased risk of diabetes and heart disease that goes along with this condition, it is very important to have your blood sugar and your cholesterol tested periodically. The American Diabetes Association suggests that people with this condition should have periodic blood sugar tests.

Expected duration

This problem begins in puberty and lasts until the ovaries stop producing hormones due to menopause. The insulin resistance, high insulin levels, diabetes risk and heart disease risk usually last throughout life.

Prevention

There is currently no way for most people to prevent polycystic ovary syndrome. Our understanding of problems relating to insulin resistance is improving rapidly, and some scientists are hopeful that we eventually will be able to prevent some cases of polycystic ovary syndrome if we can identify and treat insulin resistance in its earliest stages.

Treatment for polycystic ovary disease can prevent complications such as uterine cancer. Because you have an increased risk of heart disease if you have this condition, it is very important that you avoid smoking, maintain a healthy exercise regimen and follow a healthy diet.

If you have epilepsy and you have any features of polycystic ovary syndrome, you probably want to take other anti-seizure medicines rather than valproic acid (Depakote, Depakene). This medicine affects the metabolism of some reproductive hormones within the body, and may worsen your symptoms.

Treatment

Weight loss, diet and exercise are recommended for all women with polycystic ovary disease to prevent obesity and to help prevent heart disease and diabetes. Other treatment of polycystic ovary syndrome depends upon your symptoms and whether you want to become pregnant.

Restoring normal menstrual cycles can help reduce the risk of cancer in the uterus. This can be accomplished using pill supplements of progesterone for 10 to 14 days each month. Another way to restore menstrual cycles is to take birth control pills that contain both estrogen and progesterone. The estrogen seems to signal the ovaries that they can take a break from producing female sex hormones. In women who are taking birth control pills, the ovaries also decrease their production of androgens. After six months on birth control pills, side effects of hair growth and acne usually show significant improvement.

For women who still have problems with unwanted hair and acne, an anti-androgen medicine can help. The most commonly used anti-androgen medicine is spironolactone (Aldactone), although others are available. Plucking or cosmetic laser treatment (electrolysis) also can be used for hair removal.

It is now possible to help about 75% of women with this condition to become pregnant. Clomiphene citrate is the main treatment. This is a medicine that helps the ovary to release its eggs.

Your doctor may prescribe diabetes medicines that reduce insulin resistance. Several diabetes medicines — such as metformin (Glucophage, generic versions) and pioglitazone (Actos, generic versions) — can decrease testosterone levels, restore normal menstrual cycles and restore fertility.

If they occur along with polycystic ovary syndrome, high cholesterol, high blood pressure or diabetes should be treated. Although surgery used to be a common treatment for polycystic ovaries, it is used only rarely now. Removing a section or sections of the ovary with procedures called wedge resection or ovarian drilling can decrease the amount of androgen hormones in the body and temporarily improve symptoms.

When to call a professional

If you have any of the symptoms of polycystic ovary syndrome, you should see your health care professional, especially if you have had irregular periods for more than six months.

Prognosis

With treatment, symptoms may improve or go away. Women with polycystic ovary syndrome need to pay strict attention throughout their life to ways they can reduce their risks of heart disease and diabetes.

Additional info

American College of Obstetricians and Gynecologists
https://www.acog.org/