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Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome (also referred to as Stein-Leventhal syndrome,
polycystic ovarian disease or hyperandrogenic chronic anovulation) is an
endocrine disorder found in 5%-10% women.
Causes
No one knows the exact cause of PCOS, but studies are looking at
whether it is caused by genetics. Also, because many women with PCOS
also have diabetes, studies are examining the relationship between
PCOS and the body’s ability to produce insulin. There is a lot of
evidence that high levels of insulin contribute to increased
production of androgen, which worsens the symptoms of PCOS. Lastly,
the medication valproate, used to treat seizures may cause or worsen
the symptoms of PCOS. Switching medications seems to help the
condition.
Estrogen and progesterone are the female hormones
produced by the ovaries that cause monthly menstrual cycles to occur. However,
a third hormone, testosterone, also is produced by the ovaries, usually
in small amounts. Testosterone is in a broad class of hormones called androgens,
and it is the dominant sex hormone in men.
In PCOS, a cycle starts wherein the body becomes resistant
to insulin, leading to the release of more and more insulin to compensate.
This condition is called hyperinsulinemia. The ovaries of PCOS women seem
to be particularly sensitive to high blood levels of insulin and respond
by overproducing androgens (such as testosterone). This disrupts the "feedback
loop" between the ovaries and the pituitary gland, and the pituitary gland
produces too much LH (luteinizing hormone), leading to more overproduction
of androgens. The immature follicles in the ovaries then fail to convert
the excess androgens to estrogen, which inhibits the development of the
follicle. Ovulation doesn't take place because the egg couldn't develop
properly, and the immature egg, instead of being released from the ovary,
becomes a tiny cyst that starts producing its own supply of androgens, which
interferes with next month's developing follicle.
No one is certain why insulin resistance occurs. It is thought
that polycystic ovary syndrome, like most cases of insulin resistance, is
caused by an inherited gene defect.
Symptoms
Polycystic ovary syndrome is not usually a cause of 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 percent to 50 percent 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
- Appearance of darkened, thickened skin, sometimes appearing velvetlike,
in the armpits.
- High blood pressure, high blood sugar or a cholesterol problem
- Insulin resistance (now thought to be a cause rather than a symptom,
more on this later). When insulin resistance is found along with high
blood pressure, high triclyceride levels, decreased HDL (good cholesterol)
and obesity, it is sometimes termed "Syndrome X".
- Higher risk of developing coronary heart disease
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Diagnosis
It is generally diagnosed through various blood tests and ultrasound.
It shouldn't be diagnosed by ultrasound alone, though, because about 20%
of women have polycystic-appearing ovaries - it's a symptom of chronic anovulation,
which can be caused by other things. Blood tests can be done to test a number
of different hormone levels - high androgen levels (particularly free testosterone),
high levels of LH or elevated LH to FSH (follicle stimulating hormone) ratio
are often the basis for diagnosis.
Treatment
Birth control pills (oral contraceptives) that contain female hormones
can bring on more regular periods and help treat the problem of irregular
menstrual cycles. These contraceptive pills help to lower levels of androgens
and can improve acne and hair growth as well.
Insulin-sensitizing medications are useful for many women with PCOS. By
lowering insulin levels, they improve the regularity of menstrual cycles
in about half the women who try them. Metformin is the drug of choice, but
doctors should prescribe the drug with caution. There is not yet enough
information to recommend this drug for all women with PCOS. (Another similar
acting drug, troglitazone, was removed from the market because of liver
damage in patients who had diabetes). Ask your doctor about metformin. It
may be helpful in some women to induce ovulation and may play a role in
preventing early pregnancy loss. It has been used during pregnancy but there
is no consensus on this use at present.
It is now possible to help about 75 percent of women
with this condition to become pregnant. Clomiphene citrate (Clomid, Milophene,
Serophene), a medicine that assists the ovary to release its eggs, is the
main treatment.
Androgen-lowering drugs can be used to treat several PCOS symptoms. Spironolactone
and finasteride can help to relieve the symptoms of excessive or thinning
hair and acne. They can be taken along with oral contraceptives.
An anti-hair-growth drug also can help to slow the growth of facial hair
in women with PCOS. The drug is not a depilatory that loosens and gets ride
of hair. Eflornithine hydrochloride, the active ingredient, blocks an enzyme
found in the hair follicle of the skin that is needed for hair growth. This
results in slower hair growth after a few weeks of treatment.
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