Written by:

Dr Konstantinos Palaiologos

MD

Dr Konstantinos Palaiologos (MD), is a specialty trainee in Obstetrics and Gynaecology in the Yorkshire and the Humber area. He has a passion for promoting best health care for women and he is looking forward to developing his interest in fertility and benign gynaecology.

Polycystic ovary syndrome

In this article:

  • What causes PCOS?
  • Symptoms of PCOS
  • Testing for PCOS
  • What complications can PCOS lead to?
  • How does PCOS affect fertility?
  • How does PCOS affect pregnancy?
  • Main Points
  • References:

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a set of symptoms that can have an impact on periods, fertility, hormones, and aspects of your appearance, and the condition might have a long-term effect in your health. It is a common condition that affects 2 to 6 in every 100 women.

What causes PCOS?

The cause of this condition is not yet fully known and it might be due to a combination of genetic and environmental factors. It often runs in families, and the risk of developing PCOS may be increased if one of your relatives (mother, aunt, sister) is affected by the syndrome.

PCOS is mainly related to abnormal hormone levels:

  • Testosterone, which is a hormone produced physiologically in small amounts by the ovaries and is usually higher in men than women, is found to be increased in women with PCOS.
  • Insulin is a hormone that controls the level of sugar in the blood (glucose). PCOS is associated with insulin resistance, which means that the body does not respond well to insulin, and that often causes the level of glucose to be higher than normal. This results in an increased production of insulin from the body to control the high glucose levels. High levels of insulin can lead to higher levels of testosterone, fertility problems, menstrual disorders and weight gain.

Symptoms of PCOS

The symptoms vary from woman to woman. Some women have few mild symptoms while others can be affected severely by a wide range of symptoms. These include:

  • Menstrual disorders such as irregular periods or no periods at all
  • Increase facial or body hair, also known as hirsutism
  • Loss of hair on your head
  • Problems with weight such as central obesity, being overweight, rapid increase in weight or difficulty losing weight
  • Oily skin, acne
  • Difficulty becoming pregnant due to lack of ovulation

Testing for PCOS

Tests are carried out to help to diagnose polycystic ovary syndrome are:

  • Blood tests to check hormone levels
  • Pelvic ultrasound scan to assess the ovaries

PCOS is diagnosed according to the Rotterdam consensus criteria. To be diagnosed with PCOS you need to have any two of the following:

  • Ovulatory dysfunction (irregular, infrequent periods or no periods at all)
  • Hyperandrogenism (higher testosterone levels than normal, increase in facial or body hair)
  • Polycystic ovaries (enlarged ovaries)

What complications can PCOS lead to?

PCOS is associated with long-term health problems, including:

  • Diabetes – Approximately 1 or 2 in every 10 women with PCOS will develop diabetes at some point due to high blood glucose levels.
  • Hypertension – there is an increased risk of developing high blood pressure. This is more likely related due to insulin resistance and being overweight rather than PCOS itself.
  • Cardiovascular Disease – there is an increased risk secondary to high blood pressure.
  • Endometrial Cancer – if you do not have your period (menstrual bleeding) for more than 3-4 months, the lining of your womb (endometrium) can become thickened, leading to endometrial cancer in a small number of women.
  • Emotional wellbeing and challenges such as depression, anxiety, mood swings and low self-esteem.
  • Fatigue, sleepiness during the day, and snoring.

How does PCOS affect fertility?

Most women with PCOS achieve their desired family size; however, for some of them medical support might be needed. Around 70% of women with PCOS may experience problems getting pregnant. For those women, a common cause of infertility might be anovulation or infrequent ovulation.

Every month in women of childbearing age, tiny fluid-filled cysts called follicles develop on the surface of the ovary. One of them will mature and produce an egg which is then released from the ovary. In this process, female hormones play a vital role. In PCOS your body does not produce the hormones necessary for regular ovulation. Due to this imbalance of the female hormones and the increased amount of male hormones, mature eggs are often prevented from developing and being released. Ovulation fails to occur and this may result in an irregular or absent menstrual cycle. The follicles continue to be present without releasing eggs, and this attributes to the appearance of the ovaries being bigger than usual.

We need to bear in mind that there might be other factors of PCOS that can contribute to infertility such as changed levels of gonadotropins and an excessive amount of insulin. Last but not least, like women without PCOS, women with PCOS who are ovulating may be infertile due to other causes such as tubal blockages.

The management of infertility in women with PCOS consists of lifestyle changes, medical treatment and surgical intervention. Women with PCOS and infertility who have a BMI of 30 or over will be advised to lose weight (5%-10% of weight loss of your total body weight can improve the chances of becoming pregnant). This alone may restore ovulation and have a positive impact on pregnancy outcomes. Next in line is the use of medication such as clomifene citrate or metformin or a combination of both which helps ovulation. For women who are resistant to clomifene citrate, the second line of treatment is laparoscopic ovarian drilling, which is a surgical intervention, a combined treatment of clomifene citrate and metformin if not used before, or gonadotrophins in the form of injections.

Injectable gonadotropins are hormones made in the laboratory that are very similar to the natural hormones that our brain’s pituitary gland produces. They work by stimulating the ovaries to grow follicles (tiny fluid cysts with immature eggs) and then inducing ovulation by causing the mature follicle to tear and release the egg. About 7 in 10 women with PCOS and ovulation problems will ovulate after this treatment and about 2-4 in 10 women will conceive.

If all of the induction therapies are unsuccessful and there is no other cause of infertility found, your doctor may consider the pathway of in vitro fertilization (IVF).

How does PCOS affect pregnancy?

Women with PCOS have a higher risk of complications in their pregnancy including high blood pressure, pre-eclapmsia, gestational diabetes mellitus and miscarriage. Those risks are particularly high in obese women.

There is no specific cure for PCOS. Medical approaches aim to manage and reduce the symptoms or consequences of having PCOS.

Healthy lifestyle: Changes such as exercise, healthy diet and weight control constitute the first line of management. Having a healthy balanced diet includes fruit, vegetables, lean meat, fish, chicken and whole food (wholemeal bread, whole-grain cereals, brown rice and whole-wheat pasta) and cutting down the amount of sugar, salt, caffeine and alcohol. Experts advise regular exercise for 30 minutes at least three times a week. In overweight women, loss of just 5% of your total weight can lead to significant improvement and control of PCOS symptoms.

Medication for menstrual irregularity: There is a variety of oral contraceptives and intrauterine system (IUS) to help with menstrual disorders.

Management of hirsutism: Medications to control excessive hair growth include particular types of combined oral contraceptive tablets and other anti-androgen medications that block the effects of ‘male hormones’ (testosterone). You may also want to remove the unwanted hair by other methods of cosmetic therapy such as waxing, plucking, shaving, threading, creams or laser removal.

Management of acne: There is a variety of prescription medications for moderate or severe acne such as topical retinoids; antibiotics in the form of gels, lotions or tablets; azelaic acid; and hormonal therapies (combined contraceptive pill, co-cyprindiol).

Bariatric Surgery: For women with BMI of 40 or above or of 30 and above with a high-risk obesity-related condition, weight loss surgery is an option.

Main Points

  • Polycystic ovary syndrome refers to a set of symptoms that can cause irregular periods and infertility, and the condition may also have a long-term effect on your health.
  • PCOS is common, affecting 2 to 6 in every 100 women
  • PCOS is mainly related to abnormal testosterone and insulin levels.
  • Having polycystic ovaries (larger than the normal) does not necessarily mean that you have PCOS.
  • The symptoms vary from woman to woman. Some women have few mild symptoms while others can be affected severely by a wide range of symptoms. These include irregular periods, increase in facial hair, and thinning of hair on head.
  • Blood tests to check hormone levels or a pelvic ultrasound scan to assess ovaries can be used to diagnose PCOS. The condition is diagnosed according to the Rotterdam consensus criteria.
  • PCOS is associated with long-term health problems including diabetes and high blood pressure.
  • PCOS does not increase your chance of breast or ovarian cancer but it increases the risk of endometrial cancer.
  • Around 70% of women with PCOS may experience problems getting pregnant. The common cause of this is infrequent ovulation of anovulation.
  • During ovulation, tiny fluid-filled cysts (follicles) develop on the surface of the ovary. One of these will mature and release an egg. In women with PCOS, hormonal imbalance can prevent the egg from releasing (anovulation).
  • The management of infertility in women with PCOS consists of lifestyle changes, medical treatment and surgical intervention.
  • Many women with PCOS manage their symptoms without medical or surgical intervention.
  • Women with PCOS who are obese are advised to lose weight to improve their chances of conception.
  • Medication such as clomifene citrate or metformin or a combination of both which helps ovulation.
  • Other treatment options include laparoscopic ovarian drilling and the injection of gonadotrophins, which are hormones that stimulate the ovaries.
  • IVF is another path to explore if all other induction therapies are unsuccessful.
  • Medication alone has not been shown to be better than healthy lifestyle changes such as diet, exercise and weight loss if overweight for treating PCOS.

References:

Information Leaflet: Polycystic Ovary Syndrome what it means for your long-term health, June 2015, RCOG
Fertility problems: assessment and treatment, NICE Clinical Guideline CG156, updated September 2017
NHS treatment for PCOS: https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/treatment/
Long term consequences of Polycystic Ovary Syndrome, Green-top Guideline No33, November 2014, RCOG
Clinical practice guidelines for Polycystic Ovary Syndrome, Australian NHMRC, ESHRE, ASRM July 2018
ASK PCOS Evidence based information for women with polycystic ovary syndrome, Monash University on behalf of NHMRC, Centre for Research Excellence in PCOS and the Australian PCOS Alliance 2018