16 Jul Polycystic Ovarian Syndrome (PCOS)
Jan is a 27 year old female who has always had irregular menstrual periods, but most recently she has noted longer time between her menstrual cycles and occasionally heavy, prolonged menstrual bleeding. Since her teenage years, she has had coarse hair growth on her upper lip and chin, abdomen and breasts. She frequently waxes and hair removal preparations. She also feels she has been about 30 pounds overweight and can’t seem to lose the weight. She also is recently married and has been attempting pregnancy for over a year without success. She has made an appointment with a reproductive endocrinologist and infertility specialist for further evaluation.
Does Jan likely have polycystic ovarian syndrome (P.C.O.S.)? What is PCOS?
PCOS is a disorder characterized by irregular menstrual periods and elevated male pattern hormones, or androgens, which result in male pattern hair growth (hirsutism), acne and male-pattern balding. Other common signs and symptoms of PCOS include obesity, insulin resistance, and infertility. However, a patient does not have to be obese to have PCOS. Additionally many patients with PCOS have multiple small follicles seen on their ovaries on pelvic ultrasound (this was traditionally described as “cysts”, thus giving the name “PCOS”).
What causes PCOS?
The exact causes of PCOS are unknown, but seem to be related to several different factors. There definitely seems to be a genetic component: women whose relatives have PCOS are more likely to have PCOS. Obesity and insulin resistance can contribute to the disease process.
Why does Jan have such irregular bleeding and does anything need to be done about it?
The irregular menstrual periods seen in PCOS are typically due to lack of ovulation. Each month, a woman’s ovaries usually release one egg. Hormonal changes during the menstrual cycle result in a woman getting her period if she does not become pregnant. In the setting of PCOS, a woman may infrequently ovulate or not ovulate at all. As a result, the lining in her uterus may thicken and bleed irregularly. Occasionally a woman may have significantly prolonged and heavy menstrual bleeding. Alternatively, a woman may go for months without menstrual periods. Sometimes in this setting, a health care provider may need to do testing to insure there are no abnormalities in the lining or cavity of the uterus.
If a woman with PCOS has irregular periods, but is not interested in getting pregnant, does she need to do anything about her irregular periods?
Combination birth control pills (oral contraceptive pills, or OCPs), which contain estrogen and progestin, are frequently used to help patients with irregular periods develop regular periods. Additionally, in the setting of PCOS, combination OCPs are also beneficial in that they lower androgen levels, often leading to decreased acne and hirsutism.
Why are women with PCOS likely to have infertility?
In order to conceive a pregnancy, a woman needs to ovulate, or release an egg from her ovary, and her partner’s sperm fertilize it. When a woman does not ovulate, no egg is released that is available for fertilization. Additionally, other factors common in PCOS, such as elevated androgens and obesity, may additionally contribute to infertility.
What can be done to help Jan become pregnant?
If patients are overweight or obese, weight loss can help improve the likelihood a patient will ovulate on her own and conceive on her own. A regimen of exercise and a diet lower in carbohydrates can help a patient work toward losing weight and optimize her health before pregnancy. If a patient tries any such regimen, she should be under the care of a physician. If a patient either cannot lose weight or loses weight and does not still ovulate, she may need to be treated with medications to induce ovulation. These are generally well tolerated, but have some risks (such as side effects and multiple pregnancy such as twins, triplets or more). As a result a patient taking these medications should be well monitored.
What is insulin resistance?
Insulin resistance is far more common in patients with PCOS, but a patient does not have to have insulin resistance to have PCOS. Insulin resistance is when a cells in a patient’s body do not respond normally to insulin; as a result, the body produces more insulin which results in higher blood glucose. Higher insulin levels can contribute to a larger appetite and can affect the balance of other hormones, such as androgens. Insulin resistance is diagnosed with specific blood tests.
What are signs of insulin resistance?
Any patient who is significantly overweight or obese may have insulin resistance. Signs may be an elevated waist circumference, or elevated ratio of waist circumference to hip circumference. Other signs may be acanthosis nigricans, which are patches of thickened, velvety, darkened skin typically on the neck, chest or back.
What can be done to treat insulin resistance?
Weight loss is typically beneficial. There are also medications known as insulin-sensitizing agents that can make the body more sensitive to insulin. These medications can result in lower androgen levels and some may improve the likelihood a patient ovulates. Large-scale studies still suggest that standard medications for ovulation induction are more likely to help a patient conceive a pregnancy.
What are the health risks of PCOS?
It is important a patient see a health care provider if she suspects she may have symptoms of PCOS. PCOS places a patient at risk of several significant health problems, including hyperlipidemia (elevated cholesterol), Diabetes, hypertension (high blood pressure), endometrial (uterine lining) cancer, depression, and heart disease.
What can be done to help with Jan’s hirsutism?
The most effective treatment for hirsutism involves both systemic treatments (such as OCPs or other medications to reduce androgens) and topical treatments, such as creams, waxing or laser. It should be noted that most of these treatments should not be used in women trying to get pregnant.
For further information or to schedule an appointment, please call our Reproductive Medicine Clinic at (414) 805-7370.