Polycystic ovary syndrome (PCOS) is a common hormone disorder that affects 5%-10% of reproductive-age women. We see a lot of patients with PCOS because it is one of the most common causes of ovulation problems and infertility. PCOS is a collection of problems that occur simultaneously which include: ovulation problems, high androgen levels (e.g. high testosterone), and ovaries with multiple small follicles present.
The diagnosis is one of exclusion, and based on a combination of clinical, lab, and ultrasound findings. Women with PCOS tend to be overweight with irregular periods due to lack of ovulation, have increased hair growth (hirsutism), and acne. On ultrasound, many women with PCOS have enlarged ovaries with many small cysts or follicles. Blood tests may show high blood sugar, high cholesterol levels, or high levels of male hormones. The elevated androgens are the main reason for the hair growth and acne. Not all women with PCOS have all the same combination of symptoms.
In addition to infertility, PCOS women have a higher risk of other medical problems such as diabetes and uterine cancer. The lack of periods allows the tissue in the uterus to continue growing, leading to abnormal bleeding and this tissue may eventually develop in to uterine cancer. Metabolic syndrome is also more common in PCOS women (high cholesterol, high blood pressure, insulin resistance/diabetes). Obesity is very common in PCOS, as is insulin resistance. Up to 70% of women with PCOS have insulin resistance. High levels of insulin are required to keep blood sugar levels under control, and these high insulin levels contributes to excess male hormone production and ovulation problems. Insulin resistance is a precursor to diabetes, so PCOS women are at greater risk for developing gestational diabetes and non-insulin dependent diabetes later in life. There are other complications of pregnancy that are more common in PCOS, such as pregnancy induced high blood pressure and preterm birth.
Insulin resistance is diagnosed by clinical signs or by lab testing. Acanthosis nigricans, which is a thickening and darkening of the skin around the neck, under the breasts, or under the arms, is caused by insulin resistance. Lab testing for glucose and insulin levels while fasting and after a glucose challenge can diagnose insulin resistance and diabetes. Insulin resistance is treated by weight loss, exercise, low carbohydrate diet, and insulin sensitizing medications. The most widely used medication is metformin, or Glucophage. Metformin will improve sensitivity to insulin so the body doesn’t need to make as much, and insulin levels decline. A reduction in androgens often follows, which may help with hair growth, acne, and cycle regularity. The improvement in insulin sensitivity will also help with weight loss. Unfortunately, metformin does not directly help women conceive.
Infertility caused by PCOS is best treated by ovulation induction. Clomid and letrozole (Femara) are the most commonly used oral medications to stimulate the ovaries to produce a mature egg. We prefer to use letrozole as it has fewer side effects than clomid and has a lower rate of twins. We will also perform ultrasounds to monitor the ovarian and uterine response to medication, and use an hCG injection to mimic the LH surge which ensures ovulation and controls the timing of ovulation. Approximately 15% of women will not respond to oral medications, and then need to consider using FSH (follicle stimulation hormone) injections for ovulation induction, or proceed with IVF (in vitro fertilization). One of the features of PCOS is that there are many resting, immature follicles within the ovaries, so there is a higher risk of ovarian hyperstimulation syndrome when using FSH injections. Ultrasound monitoring is always done when using FSH to assess the ovarian response and adjust the dose of FSH to prevent an excess number of follicles developing. With so many follicles available in PCOS, it is difficult to stimulate just a single follicle/egg, so the risk of multiple births is higher in PCOS when using FSH to induce ovulation. IVF is very effective in women with PCOS, and though there is a risk of ovarian hyperstimulation we typically transfer only one or two embryos into the uterus, which minimizes the chance of a multiple pregnancy.
If pregnancy is not the goal, taking birth control pills usually helps correct PCOS symptoms. The pills are an easy way to reduce extra hair growth and acne because the pill will reduce the availability of androgens to stimulate hair follicles and cause oily skin. The pill can also make menstrual periods more regular and therefore prevent uterine cancer. Diet, exercise, weight loss, and insulin sensitizing medications can help lower the risk of developing diabetes or metabolic syndrome.
Treatment should be tailored to each woman’s needs, symptoms, and particular situation which may obviously change over time. But if someone has PCOS and is trying to conceive, she will most likely need assistance with ovulation induction and we are here to help.