Polycystic Ovary Syndrome (PCOS) - Symptoms, Causes & Treatment
Polycystic ovary syndrome (PCOS) is a common hormonal problem that affects around 1 in 10 women here in the UK. It can cause irregular or absent periods, excess hair growth, acne, weight issues and fertility problems.
PCOS is linked to metabolic issues like insulin resistance, which can lead to diabetes. To diagnose PCOS, doctors will look at your symptoms, hormone levels and imaging tests to see if there are any fluid-filled sacs on the ovaries.
Treatment includes lifestyle changes, contraceptive pills and medications to manage symptoms and reduce health risks.
Symptoms
It’s important to note that not all women with polycystic ovary syndrome will display any symptoms. However, if you do have PCOS, symptoms typically appear in your late teens or early 20s.
Polycystic ovary syndrome symptoms vary from mild to severe. One of its defining features is irregular menstrual cycles, often characterised by infrequent or absent periods. This can lead to a difficulty in getting pregnant due to irregular or no ovulation.
Additionally, PCOS commonly causes hirsutism, leading to excess hair growth on the face, chest, back and other areas. Some may notice thinning scalp hair or even hair loss.
Acne and excessively oily skin are frequent skin-related symptoms. Skin changes, such as darkening of skin creases or the appearance of skin tags, can also occur.
Weight gain, especially around the abdomen, is often associated with PCOS, though not everyone with PCOS is overweight.
Fertility problems
PCOS is a common cause of infertility in women. Many discover they have PCOS when they struggle to get pregnant. In a usual menstrual cycle, ovaries release an egg (ovum) each month into the uterus (womb) through ovulation.
But with PCOS, ovulation is irregular or doesn't happen, leading to irregular periods and difficulty getting pregnant.
Risks in later life
PCOS can raise the likelihood of experiencing other health issues later in life. Specifically, women with PCOS face an increased risk of:
- Developing type 2 diabetes, a chronic condition that leads to high blood sugar levels
- Experiencing depression and mood swings, often due to the impact of PCOS symptoms on self-esteem and confidence
- Developing high blood pressure and elevated cholesterol levels, which can contribute to heart disease and stroke
- Possibly developing sleep apnea, a condition characterised by interrupted breathing during sleep, particularly among overweight women
Moreover, women who have had infrequent or absent periods (less than 3 or 4 per year) over many years have a higher risk of developing endometrial cancer (cancer of the womb lining).
However, this risk remains relatively small and can be reduced through treatments that regulate periods, such as the contraceptive pill or an intrauterine system (IUS).
Causes
Insulin resistance
The pancreas releases insulin, a hormone responsible for regulating blood sugar levels by assisting in the transfer of glucose from the bloodstream into cells for energy production.
Insulin resistance, on the other hand, indicates that the body's tissues are less responsive to the effects of insulin. Consequently, the body compensates by producing extra insulin.
Elevated insulin levels cause the ovaries to produce excessive testosterone, disrupting the development of ovarian follicles (the sacs where eggs mature) and hindering regular ovulation.
Furthermore, insulin resistance can lead to weight gain, exacerbating PCOS symptoms. Excess fat triggers increased insulin production, worsening the condition.
Hormone imbalance
Many women diagnosed with PCOS experience a hormonal imbalance, characterised by:
- Elevated levels of testosterone, a hormone typically associated with males but produced in small quantities by women
- Increased levels of luteinising hormone (LH), which normally triggers ovulation but can have abnormal effects on the ovaries when present in excess
- Reduced levels of sex hormone-binding globulin (SHBG), a blood protein that binds to testosterone, diminishing its impact
- Elevated levels of prolactin, although this is only found in some women with PCOS. Prolactin stimulates the breast glands to produce milk during pregnancy
The exact cause of these hormonal changes remains unclear. It’s suggested that these issues may originate in the ovaries themselves, other hormone-producing glands or the region of the brain responsible for regulating hormone production.
These changes could also be influenced by insulin resistance.
Genetics
PCOS can also run in families, so if close relatives like your mother, sister or aunt have PCOS, your risk of developing it may be higher.
This implies a potential genetic link to PCOS, even though the exact genes responsible for the condition have not been pinpointed yet.
Diagnosis
If you experience common symptoms of polycystic ovary syndrome, it's advisable to consult your GP. During the visit, your GP will ask about your symptoms to rule out other potential causes and assess your blood pressure.
Hormone tests will be arranged to determine if the excessive hormone production is related to PCOS or another hormone-related condition.
An ultrasound scan may also be recommended to assess the number of follicles in your ovaries, which are fluid-filled sacs where eggs develop. Additionally, a blood test will be conducted to measure hormone levels and screen for diabetes or high cholesterol.
To diagnose PCOS, your healthcare provider typically considers the following criteria. At least two out of the following three criteria should be met:
- Irregular or infrequent periods, indicating irregular ovulation
- Elevated levels of male hormones (like testosterone) in blood tests, or signs of excess male hormones, even if blood tests are normal
- Evidence of polycystic ovaries in scans
It's worth noting that an ultrasound scan may not always be necessary for a PCOS diagnosis, as only two of these criteria need to be present.
Upon a PCOS diagnosis, you may receive treatment from your GP or be referred to a specialist, such as a gynaecologist (a specialist in female reproductive system conditions) or an endocrinologist (a specialist in hormone disorders).
Your healthcare provider will work with you to develop a tailored management plan, which may include lifestyle changes and medication.
Subsequent to diagnosis, you might be offered regular blood pressure checks and diabetes screening, depending on factors like your age and weight.
Treatment
Polycystic ovary syndrome (PCOS) cannot be cured but its symptoms can be effectively managed through various treatment options.
Lifestyle changes
If you’re overweight, shedding excess weight can significantly improve PCOS symptoms and reduce the risk of long-term health issues. Even losing just 5% of your body weight can have a positive impact.
To determine a healthy weight, you can calculate your body mass index (BMI) using a BMI calculator. A healthy BMI falls within the range of 18.5 to 24.9.
In order to lose weight, you should partake in regular exercise and adopt a balanced diet rich in fruits, vegetables, whole foods, lean proteins and fish. If dietary guidance is needed, your GP may refer you to a dietitian.
Medications
Contraceptive pills or intermittent progestogen tablets may be prescribed to induce regular menstrual cycles, reducing the risk of endometrial cancer.
Additionally, the combined oral contraceptive pill is often used to address excessive hair growth (hirsutism) and hair loss (alopecia).
A cream called eflornithine can slow facial hair growth, and minoxidil can help with scalp hair loss. In some cases, anti-androgen medications such as cyproterone acetate, spironolactone and flutamide may be recommended.
Spironolactone is also used to treat hormonal acne caused by PCOS.
Clomifene is often the initial treatment for PCOS-related fertility problems, as it stimulates ovulation. Metformin, commonly used for type 2 diabetes, can help regulate menstrual cycles, lower insulin and blood sugar levels, and enhance fertility.
It also provides long-term benefits like reducing cholesterol levels and heart disease risk. Though not licensed for PCOS in the UK, metformin may be prescribed for specific cases.
Gonadotropins, administered by injection, are another option for fertility but carry a higher risk of overstimulating the ovaries and potentially resulting in multiple pregnancies.
IVF
If medication is ineffective in helping you to get pregnant, you may be offered the option of in vitro fertilisation (IVF). This procedure entails the retrieval of eggs from the ovaries and their fertilisation outside the womb. Subsequently, the fertilised egg(s) are carefully reintroduced into the womb.
It's worth noting that IVF treatment raises the likelihood of having twins or even triplets for those with PCOS.
Surgery
Laparoscopic ovarian drilling (LOD) is a surgical procedure that may be considered when medication fails to address fertility issues linked to PCOS.
During this procedure, you will be under general anaesthetic and your surgeon will make a small incision in your lower abdomen.
They will then insert a thin instrument called a laparoscope into your abdomen. With the laparoscope, the surgeon will treat the ovaries by applying heat or using a laser to target the tissue responsible for producing male hormones (androgens).
Research has shown that LOD can effectively reduce testosterone and luteinising hormone (LH) levels while increasing follicle-stimulating hormone (FSH) levels. This helps correct hormone imbalances and may restore the ovaries' normal function.
Pregnancy risks
For individuals with PCOS, pregnancy carries an elevated risk of complications including high blood pressure (hypertension), pre-eclampsia, gestational diabetes and miscarriage.
These risks are notably higher when accompanied by obesity. If you are overweight or obese, taking steps to shed excess weight before attempting to conceive can significantly reduce these risks.
