Polycystic Ovaries and Polycystic Ovary Syndrome
The term polycystic ovary (PCO) refers to ovaries that contain numerous small ovarian cysts. This problem is very common and affects a quarter of all women during their reproductive years. The ovary normally recruits more than a single follicle every month and usually around five follicles start to mature, but only one usually proceeds to full maturity and releases an egg. The other follicles do not mature and usually disappear, however, they can sometimes remain as ovarian cysts and this gives rise to PCO. At least a dozen cysts are often present, though a few ovarian cysts may be considered normal.
PCO is often asymptomatic and does not always have a significant impact on fertility. In some cases however, the hormonal system gets out of balance causing problems with ovulation along with other symptoms. This collection of symptoms is referred to as polycystic ovary syndrome (PCOS). The symptoms can include reduced or absent ovulation, raised level of male hormones and polycystic ovaries; if two of these three are present then PCOS is suspected. It is possible to have the syndrome without the appearance of many ovarian cysts, though this is not usually the case. The overall prevalence of PCOS is between 5-10% in the UK population, representing an important cause of infertility. In many cases the symptoms are mild and women don’t know they have it until they begin trying to get pregnant. In other situations however, the symptoms can be very severe and distressing.
Symptoms of PCOS
PCOS is a collection of symptoms of varying severity. Not all women experience these symptoms, in some cases they are very mild or absent, while other women may experience more severe or widespread symptoms. Around half of sufferers gain weight and have excessive hair growth to some degree.
- No periods or irregular periods
- No ovulation or irregular ovulation
- Reduced fertility
- Excessive body or facial hair (hirsutism)
- Excessive or rapid weight gain
- Oily skin, acne or other skin problems
- Thinning of scalp hair
- Elevated insulin levels or type II diabetes
- Depression or mood changes
Causes of PCOS
Because PCOS is a collection of varied symptoms it is very difficult to ascribe a single cause. The reasons for developing PCOS are still the subject of intense scientific investigation and discussion. What has emerged so far is a very complex picture of hormonal and metabolic disturbances, and it is often difficult to separate the causes from the symptoms. In fact it is likely that there are several different causes, which would explain the variety of symptoms in different women.
The main ideas that have been explored fall into three main areas. Firstly, problems may occur with the regulation of the ovary itself. These include the production of hormones by the ovary and its response to its environment. Secondly, the production of hormones (most notably LH) by the pituitary gland, or the part of the brain that controls and regulates it. Finally, resistance to insulin and increased insulin production is probably a major factor, and this may also be sometimes related to body weight and diet.
There is some evidence to suggest a genetic component in PCOS, but it does not appear to be strictly passed from parents to children. It is possible that inheriting certain combinations of genes may increase the likelihood of acquiring the syndrome, and those genes controlling signalling pathways in the ovary have come under scrutiny. As with most complex genetic situations it is possible that other environmental factors such as diet and lifestyle play a role.
Insulin and hormone imbalance
The hormone insulin is involved in controlling blood sugar levels. It increases the ability of fat and muscle to take in sugar from the blood. When blood sugar levels rise, after a meal for example, insulin is produced by the pancreas and this causes the body tissues to become more efficient at taking in the sugar, so blood sugar levels fall back to normal.
Women with PCOS often have what is called insulin resistance. This means that their body does not respond as efficiently to insulin by taking sugar out of the bloodstream into tissue. In order to keep the blood sugar levels normal, more insulin is produced.
Another effect of insulin is to make the ovaries produce increased amounts of testosterone. Although testosterone is thought of as a male hormone, it is naturally produced by the ovary where some of it is converted to oestrogen. It is just that men produce much more testosterone than women. High levels of insulin and testosterone can disrupt normal follicular development so that many follicles develop but do not proceed to full maturity, but at the same time do not disappear as normal. This gives rise to failure to ovulate and the accumulation of ovarian cysts. The high testosterone levels are also responsible for the thinning of scalp hair and excessive body and facial hair growth which sometimes accompany PCOS. Higher than normal levels of luteinising hormone (LH) is often found in women with PCOS due to higher production by the pituitary gland. LH stimulates production of oestrogen by the ovary, and works alongside insulin to cause increased testosterone production.
Excess body fat can cause the body to produce more insulin than normal and as already described the increased insulin levels can have an adverse effect on the ovary and increase testosterone production. Being overweight can make the symptoms of PCOS worse. Women with insulin resistance may also find it more difficult to lose weight as elevated insulin levels can themselves lead to weight gain.
Investigation and Diagnosis of PCOS
The first step in diagnosing PCOS is a full medical history at a consultation with your doctor so that other causes for hormonal imbalance and symptoms can be excluded. Blood tests to check for increased levels of testosterone or LH are usually carried out. Sometimes tests to detect lower than normal follicle stimulating hormone (FSH), progesterone or estrogen are undertaken. Measurements of insulin, blood glucose or cholesterol are often appropriate depending on symptoms. Very high levels of anti-mullerian hormone (AMH) are also indicative of polycystic ovaries.
Medical history and blood tests are usually followed by an ultrasound scan of the ovaries. This is a painless and routine procedure that allows the visualisation of the ovarian cysts themselves.
Treatment of PCOS
There is no absolute cure for PCOS, but its symptoms can be treated effectively in most cases. Given that PCOS varies so widely in its symptoms and probable causes, no single treatment is ideal for all women. Your doctor will discuss your individual symptoms and the best way to manage them. One of the major reasons for seeking treatment is the desire to have a baby and there are several options for treatment here. There are also some non-fertility related treatments that are aimed at reducing the sometimes distressing symptoms of PCOS.
Managing weight loss
In women who are insulin resistant the priority is to lower insulin levels. This is most naturally achieved by exercise and improved diet, especially reducing processed sugary foods. Even a modest weight loss of a few kilograms can result in reduced insulin levels and the re-establishment of ovulation and regular periods.
In some cases the medicine Metformin, used for many years in diabetes, is prescribed. Metformin makes the response to insulin in the muscles and liver last longer, and so less insulin is produced. This can help break the cycle of increased insulin causing persistence of ovarian cysts and the overproduction of testosterone. Lower insulin also makes weight loss easier when combined with an appropriate diet and exercise. Metformin has been shown to be effective in reducing the symptoms of PCOS in women who show signs of insulin resistance.
Clomiphene citrate (Clomid)
This treatment is particularly appropriate for women wishing to conceive. Clomiphene is a medicine that blocks the inhibiting action of oestrogen on the production of follicle stimulating hormone (FSH) by the pituitary gland. The effect is that more FSH is produced and this stimulates the follicles to complete their maturation. Clomid is often prescribed after, or in conjunction with Metformin.
This is a fertility treatment and involves the administration of FSH in order to stimulate the ovaries to maturity. It carries the risk of multiple pregnancy, and possible complications through overstimulation of the ovaries, so it is carried out under close supervision by the doctor and is usually monitored by ultrasound and blood tests. Ovulation may be stimulated by a trigger injection of hCG (human chorionic gonadotrophin) and in this situation intercourse can be timed accordingly.
Laparoscopic ovarian diathermy (ovarian drilling)
Laparoscopy is a kind of ‘keyhole’ surgery performed under general anaesthetic, where an laparoscope is introduced through a very small incision in the abdomen. The surgeon is able to view the ovary and make several tiny punctures in it using heat or a laser. This reduces the number of cells producing testosterone and also helps to raise FSH levels. The treatment is sometimes offered after clomid as an alternative to ovulation induction.
In vitro-fertilisation is a more comprehensive treatment which begins similar to ovulation induction in that FSH is given. In this case however, the FSH is a much higher dose which is designed to cause the maturation of many follicles. Other medicine to downregulate the natural production of FSH and LH is also taken. The development of the follicles is closely monitored by ultrasound and blood tests. When the follicles reach maturity the eggs are collected surgically and fertilised with sperm in the laboratory. Resulting embryos are carefully cultured for between 3 and 5 days before one is carefully placed into the womb. Any remaining embryos can be frozen for later use.
Other hormone treatments
Not all treatment for PCOS is geared towards fertility, indeed, alleviating other symptoms and addressing insulin resistance alone are important objectives. The distressing effects of high testosterone on facial hair growth thinning of scalp hair are often treated using anti-androgens. These drugs either block the effects of testosterone on the body, or prevent testosterone being converted to more active forms and are helpful in the improvement of acne, excess hair and scalp hair loss. Scalp hair loss in particular should be treated early as it is the most difficult symptom to reverse.
In some cases where fertility is not a concern, the oral contraceptive pill has been used to treat PCOS. This alleviates some of the symptoms of hair growth and acne etc, in that it can reduce the amount of testosterone produced by the ovary and also make periods more regular.
Unwanted hair growth can also be treated with a cream called Eflornithine which blocks the action of an enzyme found in hair follicles that is needed for hair growth. It is not a hair removal cream, but does slow down hair growth and is often used alongside a hair removal product. Treatment for acne may be offered using topical skin creams or lotions. These come in a variety of types and include antibiotics which reduce the number of dead bacteria clogging up the skin pores, or preparations that reduce the amount of oil produced by the skin.
In some cases weight loss medicines may also be prescribed in conjunction with a controlled diet and exercise programme.
Our understanding of PCOS is increasing all the time, and though the syndrome appears to have multiple causes and a complex array of side effects, there are many treatment approaches that not only preserve fertility but control the sometimes distressing symptoms.
It is important that women with suspected PCOS have the cause of their problem determined. If insulin resistance plays a large part then there is an increased risk of diabetes, heart disease and stroke and these issues must be addressed in their own right. Each case of PCOS is somewhat unique and there is no single approach that is perfect for all women. Careful diagnosis and thorough consultation with your fertility doctor or endocrinologist should result in the best combination of therapy appropriate to your needs.
Science Director Concept Fertility Clinic www.conceptfertility.com