Women’s Health: Polycystic Ovary Syndrome (PCOS)

What is PCOS?

Polycystic ovary syndrome (PCOS) is a common condition that affects how a woman's ovaries work.

The 3 main features of PCOS

Irregular periods – you do not ovulate each month, meaning your ovaries do not regularly release eggs. Although the ovaries usually have many follicles, they do not develop fully and therefore ovulation does not occur. If you do not ovulate then you may not have a period.
Polycystic ovaries – your ovaries become enlarged and at least 12 tiny fluid-filled cysts or follicles that surround the eggs develop in your ovaries. Despite the name (polycystic – meaning ‘many cysts’) you do not actually have cysts if you have PCOS.
Excess androgen – the balance of hormones you make in the ovaries is altered, causing high levels of “male” hormones in your body, which may cause physical signs such as excess facial or body hair

If you have at least 2 of these features, you may be diagnosed with PCOS. It is possible to have ovaries that are polycystic without having the typical symptoms of PCOS. It is also possible to have PCOS without having multiple cysts in the ovary.

Polycystic ovaries

Polycystic ovaries contain a large number of harmless follicles that are up to 8mm (approximately 0.3in) in size. The follicles are underdeveloped sacs in which eggs develop. In PCOS, these sacs are often unable to release an egg, which means ovulation does not take place.

It's difficult to know exactly how many women have PCOS, but it's thought to be very common, affecting about 1 in every 5 women in the UK. More than half of these women do not have any symptoms. Many of these women are healthy, ovulate normally and do not have high levels of male hormones.

Symptoms of PCOS

If you have signs and symptoms of PCOS, they'll usually become apparent during your late teens or early 20s and can include:

Irregular periods or no periods at all. Period problems occur in about 7 in 10 women with PCOS
Difficulty getting pregnant as a result of irregular ovulation or failure to ovulate
Excessive hair growth – this occurs in more than half of women with PCOS - usually on the face, lower tummy, chest, back or buttocks. In other words, it tends to be male-pattern hair.
Weight gain – women with PCOS are more at risk of becoming overweight or obese
Thinning hair and hair loss from the head
Oily skin or acne – this may persist beyond the normal teenage years
Depression or poor self-esteem may develop as a result of other symptoms

Not all symptoms occur in all women with PCOS. For example, some women with PCOS have some excess hair growth but have normal periods and fertility.

Symptoms can vary from mild to severe. Women with severe PCOS can have marked hair growth, infertility and obesity.

Symptoms may also change over the years. For example, acne may become less of a problem in middle-age but hair growth may become more noticeable.

Causes

The exact cause of PCOS is unknown, but it often runs in families. It is related to abnormal hormone levels in the body, including high levels of insulin. Several other factors likely play a part.

Insulin resistance

Insulin is a hormone that controls sugar levels in the body. Many women with PCOS are resistant to the action of insulin in their body and produce higher levels of insulin to keep blood sugar levels normal. This contributes to the increased production and activity of hormones like testosterone.

A high level of insulin and testosterone causes problems with ovulation - hence, period problems and reduced fertility. It is this increased testosterone level in the blood that causes excess hair growth on the body and thinning of the scalp hair. Increased insulin also contributes towards weight gain.

Weight

Being overweight or obese is not the underlying cause of PCOS. However, if you are overweight or obese, excess fat can make insulin resistance worse. This may then cause the level of insulin to rise even further. High levels of insulin can contribute to further weight gain producing a 'vicious cycle'. Losing weight, although difficult, can help break this cycle.

Luteinising hormone (LH)

This hormone is made in the pituitary gland, which is located in the base of the brain. It stimulates the ovaries to ovulate and works alongside insulin to promote testosterone production. A high level of LH is found in about 4 in 10 women with PCOS. A high LH level combined with a high insulin level means that the ovaries are likely to produce too much testosterone.

Hereditary factors

PCOS is not usually inherited from parents but it may run in some families. There seems to be a hereditary (genetic) factor involved in some cases but this is not yet understood.

Diagnosis

Tests may be advised to clarify the diagnosis and to rule out other hormone conditions.

Blood tests may be taken to measure certain hormones. For example, a test to measure the male hormone testosterone and luteinising hormone (LH)
An ultrasound scan of the ovaries may be advised. The scan can detect the typical appearance of PCOS with the many small cysts in slightly enlarged ovaries.
You may be advised to have an annual screening test for diabetes or impaired glucose tolerance (pre-diabetes).
A regular check for other cardiovascular risk factors such as blood pressure and blood cholesterol, may be advised to detect any abnormalities as early as possible.
Exactly when and how often the checks are done depends on your age, your weight and other factors. After the age of 40, these tests are usually recommended every three years

Treatment

There is no cure for PCOS. However, symptoms can be treated and your health risks can be reduced.

Speak to a GP if you think you may have the condition.

If you have PCOS and you're overweight, losing weightand eating a healthy, balanced diet can make some symptoms better.
Medications are also available to treat symptoms such as excessive hair growth, irregular periods and fertility problems.
If fertility medications are not effective, a simple surgical procedure called laparoscopic ovarian drilling (LOD) may be recommended. This involves using heat or a laser to destroy the tissue in the ovaries that's producing androgens, such as testosterone.

With treatment, most women with PCOS are able to get pregnant.

Treating hair growth

Unwanted hair can be removed by:

Shaving
Waxing
Hair-removing creams
Electrolysis
Laser treatments - these need repeating every now and then, although electrolysis and laser treatments may be more long-lasting

Medicines taken orally can also treat hair growth. They work by reducing the amount of testosterone that you make, or by blocking its effect. Medicines used include:

Cyproterone acetate - an anti-testosterone medicine. This is commonly combined with oestrogen as a special oral contraceptive pill called Dianette®. Dianette® is commonly prescribed to regulate periods, to help reduce hair growth, to reduce acne and as a good contraceptive.
The combined oral contraceptive pill Yasmin®(a combination of ethinylestradiol and drospirenone) has been shown to help if Dianette® is not suitable.
Other anti-testosterone medicines are sometimes advised by a specialist if the above treatments do not help.

Medicines taken by mouth to treat hair growth take 3-9 months to work fully. You need to carry on taking them, otherwise hair growth will come back. Removing hair by the methods above (shaving, etc) may be advised whilst waiting for a medicine to work.

Treating acne

The treatments used for acne in women with PCOS are no different to the usual treatments for acne.

The combined oral contraceptive pills, especially Dianette®, often help to improve acne.

Treating period problems

Some women who have no periods, or have infrequent periods, do not want any treatment for this. However, your risk of developing cancer of the womb (uterus) may be increased if you have no periods for a long time.

Some women with PCOS are advised to take the contraceptive pill, as it causes regular withdrawal bleeds similar to periods.
If this is not suitable, another option is to take a progestogen hormone, such as medroxyprogesterone for several days every few months. This will cause a monthly bleed like a period.
Sometimes, an intrauterine system (IUS), which releases small amounts of progesterone into the womb, preventing a build-up of the lining, can be used.
If none of these methods is suitable, your doctor may advise a regular ultrasound scan of your uterus to detect any problems early

Fertility issues

Although fertility is often reduced, you still need contraception if you want to be sure of not getting pregnant. The chance of becoming pregnant depends on how often you ovulate. Some women with PCOS ovulate now and then, others not at all.

If you do not ovulate but want to become pregnant then fertility treatments may be recommended by a specialist and have a good chance of success. Tablets such as clomifene can cause you to ovulate.

You are much less likely to become pregnant if you are obese. If you are obese or overweight then losing weight is advised in addition to other fertility treatments.

Complications

If you have PCOS, over time you have an increased risk of:

Developing type 2 diabetes & diabetes in pregnancy
High cholesterol
High blood pressure
Being overweight, particularly around the tummy

These problems in turn may also increase your risk of having a stroke and heart disease in later life. These increased health risks are due to the long-term insulin resistance.

A sleeping problem called sleep apnoea is also more common than average in women with PCOS.

Other possible problems in pregnancy include more chance of having babies too early or having high blood pressure in pregnancy (pre-eclampsia). There may be twice the risk of developing diabetes in pregnancy if you have PCOS so you would be checked for this regularly.

If you have no periods, or very infrequent periods, you may have a higher-than-average risk of developing cancer of the womb (uterus).

Preventing long-term problems

A healthy lifestyle is important to help prevent these conditions. For example, you should:

Eat a healthy diet
Exercise regularly
Lose weight if you are overweight or obese
Not smoke

Information adapted from NHS, Patient Info and Health Journal