Polycystic ovarian syndrome (PCOS) is common. It can cause absent, infrequent or heavy periods, reduced fertility, excess hair growth, and acne, and weight problems. Treatment includes weight loss if overweight, lifestyle changes in addition to treating individual symptoms.
How the ovaries work
The ovaries lie on either side of the womb, and are walnut-sized. They produce eggs and various hormones.
• Ovulation normally occurs once a month when you release an egg, which is caught by a Fallopian tube leading into the womb. Before an egg is released, it develops within a small swelling or cyst of the ovary called a follicle. Each month several follicles start to develop, but normally just one fully develops and goes on to ovulate.
• The main hormones that are made in the ovaries are oestrogen and progesterone – the main female hormones. These hormones make the breasts grow, and control the periods. The ovaries also make small amounts of male hormones such as testosterone.
What is polycystic ovarian syndrome?
PCOS is where at least two of the following occur:
• At least 12 follicles can be seen on scan to develop in each of your ovaries.
• The balance of hormones made in the ovaries is altered. In particular, your ovaries make more male hormone than normal.
• You do not ovulate regularly. Some women do not ovulate at all. In PCOS, although their are many follicles, they do not develop fully and so ovulation often does not occur. If you don’t ovulate then you don’t have a period.
It is possible to have just the polycystic ovaries without the typical symptoms. It is also possible to have the symptoms and a diagnosis of PCOS without multiple cysts in the ovary.
How common is PCOS?
Very common. 1 in 4 young women have polycystic ovaries (ovaries with many small cysts). However, many of these women were healthy, ovulated normally, and did not have high levels of male hormones.
At least 1 in 10 women have polycystic ovary syndrome (PCOS) – that is, at least two of: polycystic ovaries, a raised level of male hormone, and/or reduced ovulation.
What causes PCOS?
Several factors probably play a part:
Insulin is made in your pancreas, and controls your blood sugar level. Another effect is to act on the ovaries to cause them to produce male hormone. Women with PCOS have insulin resistance. More insulin is needed to keep the blood sugar normal. This also causes the ovaries to make too much male hormone. This interferes with the normal development of follicles in the ovaries, so many develop but not fully. This causes problems with ovulation, hence period problems and reduced fertility. The increased male hormone causes excess hair growth on the body and thinning of the hair. Increased insulin increases weight.
Your genetic makeup is important. One or more genes may make you more prone to developing PCOS. PCOS may run in some families.
Being overweight is not the underlying cause of PCOS. However, if you are overweight, this can make insulin resistance worse, causing the level of insulin to rise even further. This gives further weight gain producing a vicious cycle. Losing weight, although difficult, can help break this cycle.
What are the symptoms of polycystic ovary syndrome?
• Period problems occur frequently. You may have irregular or light periods, or no periods at all. When your period eventually comes it might be very heavy.
• Fertility problems – women need to ovulate to be fertile. Women with PCOS ovulate infrequently or not at all. Even if they do ovulate, the womb lining is disordered preventing an embryo implanting. PCOS is one of the most common causes of infertility.
• Excess hair growth (hirsutism) occurs in more than half of women with PCOS. It is mainly on the face, lower abdomen, and chest. This can be the only symptom.
• Thinning of scalp hair occurs in some cases.
• Weight gain – about 4 in 10 women with PCOS become overweight.
• Depression or poor self-esteem may develop as a result of the other symptoms.
Symptoms typically begin in the late teens or early 20s. Not all symptoms occur in all women with PCOS. For example, some women have excess hair growth, but have normal periods and fertility.
Symptoms can vary from mild to severe. Symptoms may also change over the years eg. acne may become less of a problem in middle age, but hair growth may become more of a problem.
Possible long-term effects of PCOS
An increased risk of developing type 2 diabetes and diabetes in pregnancy. 1 in 10 women develop diabetes at some point. These increased health risks are due to the long-term insulin resistance (and also being overweight which is common in women with PCOS).
If you have few or no periods, you may have a higher than average risk of developing cancer of the womb. This risk is probably small, but it’s important to have at least 4 periods per year and we can help with that.
Which tests are needed?
Tests are to diagnosis and to rule out other hormone conditions.
• Blood tests may be taken to measure certain hormones, and rule out rare other conditions.
• An ultrasound scan of the ovaries can show the typical appearance of PCOS with many follicles in slightly enlarged ovaries.
• An annual screening test for diabetes or pre-diabetes is recommended – your GP will do this.
What is the treatment for PCOS?
There is no cure for PCOS. However, symptoms can be treated, and your health risks can be reduced.
You should aim to lose weight if you are overweight.
Losing weight reduces the high insulin level and male hormone that occurs in PCOS. This then improves the chance of your ovulating, which improves any period problems, fertility, and may also help to reduce hair growth and acne. The risk of diabetes is also reduced. Losing weight can be difficult. A combination of eating less and exercising more is best. Advice from a dietician or Weightwatchers is helpful. Even a moderate amount of weight loss (10%) can help.
Treating hair growth
Hair growth is due to the increased level of the hormone testosterone .
• Unwanted hair can be removed by shaving, waxing, hair-removing creams, electrolysis, and laser treatments.
• Cyproterone acetate. This is given as a special contraceptive pill called Diane®. Diane® is commonly prescribed to regulate periods, to help reduce hair & acne, and is a good contraceptive.
• The normal contraceptive pill has been shown to help if Diane® is not suitable.
• Other drugs are sometimes advised by a specialist if the above treatments do not help.
These drugs take 3-9 months to work fully. You need then to carry on taking them otherwise hair growth will recur.
The combined contraceptive pills, especially Diane® often help to improve acne. Again, they take a while to work. Other treatments for acne can be used at the same time eg. lotions, antibiotics etc
Treating period problems
Some women who have no periods, or infrequent periods, do not want any treatment for this. However, your risk of developing cancer of the womb may be increased if you have no periods for a long time. Regular periods, at least 4 times a year, will prevent this possible increased risk.
Because of this, some women with PCOS are advised to take the contraceptive pill to give regular periods. If this is not suitable, another option is to take a progestogen hormone for several days every month which will cause a monthly bleed like a period. Sometimes, a Mirena 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.
Although fertility is often reduced, you still need contraception if you want to be sure of not getting pregnant. The pill, especially Diane, is usually the best choice. 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, fertility treatments may be needed and have a good chance of success. If you are overweight then losing weight increases your chances significantly.
Metformin is a drug that makes the body’s cells more sensitive to insulin. For certain people with PCOS, a specialist may advise that you take metformin.
Preventing long-term problems
A healthy lifestyle is important to help prevent the conditions listed above. You should have a healthy diet, exercise regularly, lose weight if you are overweight. It is very important not to smoke.