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Polycystic Ovary Syndrome (PCOS)Polycystic ovary syndrome (PCOS) is a hormonal disorder characterised by an excess of the hormones androgens. Androgens, which include the hormone testosterone, are often referred to as ‘male hormones’. While produced by both the male and female body, the hormones are found in much larger quantities in males. The excess of androgens has a masculinising effect on the female body and interferes with the levels of other hormones. These hormonal imbalances cause disruptions to a woman’s normal menstrual cycle. Without the appropriate levels of hormones the follicles in the ovaries never fully mature and ovulation does not occur (ie. an egg is not released). The partially developed follicles turn into small cysts on the ovaries, hence the term ‘polycystic ovaries’. It is important, however, to note that not all women with polycystic ovaries have polycystic ovary syndrome. That is, not all women with the characteristic ovarian cysts experience the symptoms associated with the syndrome. It is estimated that around 20% of premenopausal women have polycystic ovaries, but only 5-10% of the women have the actual syndrome (1). While the exact cause of the condition is unknown it appears that it has a hereditary component. For example, sisters of women with PCOS have up to a 50% chance of exhibiting symptoms of the condition (2). SymptomsWomen with PCOS commonly experience a range of symptoms associated with androgen excess including excess hair growth (hirsutism) and acne. An increased growth of coarse hair can occur on the face (sideburn area, chin, upper-lip), nipple, chest, thighs or in the middle of the lower abdomen. For many women, hirsutism is extremely distressing, affecting their self esteem and body image. Women may be too embarrassed to consult professionals qualified at hair removal, instead resorting to home treatments which are often unsuitable for the control of hormonal hair growth. While professional treatments such as electrolysis are effective at treating hirsutism, they can be time-consuming, costly and even painful. Some women also suffer from male-patterned hair loss (alopecia) which is equally distressing. Acne can also have an adverse impact on the way a woman feels about herself. Because we usually associate acne with adolescence, women who continue to get acne well after this time find it frustrating and embarrassing. In addition, the moderate to severe acne usually associated with PCOS can result in unsightly scarring. A further common symptom of PCOS is obesity, with up to 70% of women being affected (3). Women with PCOS tend to gain weight in the abdominal region rather than on the buttocks or thighs, the more common areas for female weight gain. This ‘apple’ shape carries a higher risk of health problems such as cardiovascular disease than a ‘pear’ shape (ie. more weight distribution on buttocks, thighs). In many cases, these weight problems are related to ‘insulin resistance’, a condition commonly associated with PCOS (although some women with PCOS who have insulin resistance are of normal weight). Insulin is a hormone that allows the conversion of glucose (sugar) into energy. When insulin resistance occurs, the body produces more of the hormone to compensate for it. Consequently, the elevated insulin level stimulates the body’s fat cells to make fat from nutrients and to store it, causing a woman to put on weight (4). The now enlarged fat cells, in turn, release a hormone that makes the body’s cells even more resistant to insulin which boosts insulin production even further. A high level of insulin also causes an increase in the production of androgens by the ovaries. Women with PCOS also experience menstrual disturbances: very light or heavy bleeding; infrequent periods (oligomenorrhoea); or absence of periods (amenorrhoea). The majority of women with PCOS begin having periods at a normal age but they are usually irregular and over time can disappear altogether (5). As irregular periods are quite normal during adolescence these menstrual disturbances are often not initially investigated. Women with troublesome periods and/or acne may be prescribed the oral contraceptive pill which eliminates a ‘true’ period altogether. With the menstrual-related symptoms no longer apparent, PCOS can go undetected. For some women, PCOS is only diagnosed following investigations for fertility problems. It is estimated that PCOS is present in more than 70% of women with infertility due to ovulation failure (6). Some research findings also suggest that women with high androgen levels, such as those with PCOS, have an increased risk of miscarriage (7). In addition to the troubling physical symptoms of PCOS, the condition also has long term health implications. For example, women with PCOS have an increased risk of developing Type 2 diabetes (non-insulin dependent diabetes). It is estimated that by the age of 40 up to 40% of women with PCOS will have Type 2 diabetes or impaired glucose tolerance (8). Women with PCOS also have an increased risk of cardiovascular disease. This is because the high levels of androgens tend to increase a person’s level of ‘bad’ cholesterol (LDL) and lower the level of ‘good’ cholesterol (HDL) (9). It is estimated that women with PCOS have at least seven times the risk of having a heart attack than women without the condition (10). PCOS also places women at risk of endometrial hyperplasia, a condition in which the endometrium (lining of the uterus) is overstimulated by oestrogen and becomes overgrown (11). Endometrial hyperplasia is associated with irregular ovulation. In women who experience chronic anovulation, such as those with PCOS, the resultant hyperplasia increases the risk of endometrial cancer. Diagnosis and treatmentAs many of the symptoms of PCOS have a cosmetic impact (obesity, acne and hirsutism) women may not initially seek help from their medical practitioner but instead visit a beauty therapist or a weight loss clinic. If a woman does consult her medical practitioner they may not suspect PCOS if all the obvious symptoms are not present (ie. a woman who has hirsutism but is lean may not be investigated for PCOS). Similarly, if the symptom a woman presents with improves with treatment (ie. acne helped by oral contraceptives) the underlying condition of PCOS may not be picked up until much later. Consequently, women with PCOS may go undiagnosed for many years, putting them at high risk of long term health problems like diabetes and cardiovascular disease. Diagnosis of PCOS usually involves taking a thorough medical history, conducting an ultrasound of the ovaries and blood tests to determine hormone levels. The type of ultrasound used is a transvaginal ultrasound which involves placing a probe inside the vagina. Transvaginal ultrasonography is used in preference to the usual abdominal ultrasonography as it provides a better quality image. Blood tests will indicate if a woman has elevated levels of androgens and insulin or any other hormonal imbalances. Treatment for PCOS depends on the symptoms experienced by the woman and on whether she is seeking to become pregnant. For women who are diagnosed with PCOS as a result of infertility investigations, the immediate treatment/s focus on re-establishing regular ovulation to improve the chance of pregnancy. The aim of treatment for women not wishing to become pregnant in the near future is to provide relief from the various symptoms. In the past, treatments for PCOS often only focused on the cosmetic symptoms like acne, hirsutism and obesity. Today, however, treatment for PCOS also seeks to address the long term health implications such as the increased risk of diabetes and cardiovascular disease. Lifestyle changes are considered the first line of treatment for PCOS. Women are encouraged to lose weight as this helps to restore ovulation and to reduce the various symptoms. Weight loss also reduces a woman’s risks of developing diabetes and cardiovascular disease. Women with PCOS, however, often find it difficult to lose weight using reduced-calorie or reduced-fat diets. It is now thought that these women benefit more from an eating plan specifically designed for people with insulin resistance or, in other words, a diet similar to that followed by diabetics. A diabetic diet not only concentrates on reducing fat in the diet but also focuses on the role of carbohydrates. Recently, carbohydrates were classified according to the Glycaemic Index (GI) (12). Different foods are given different GI ratings according to how long it takes for the carbohydrates to break down and enter the blood stream. Foods with a low GI rating are preferable for people with diabetes as they provide a slower, sustained blood sugar response (13). These foods are also useful for weight loss as they tend to satisfy people’s hunger more than foods with a high GI rating. The GI ratings of foods are dependent on a range of factors including the type of carbohydrate/s present and the processing and cooking methods used. Therefore, there are wide variations in GI ratings, even within a particular food group. For example, watermelon has a high GI rating (72) while grapefruit and cherries have a low rating (only 25). Similarly, a French baguette has a high GI rating (95) compared with wholegrain wheat bread (46) and wholemeal spaghetti (42). However, as Marilyn Glenville explains in her book, Natural Alternatives to Dieting, "as fascinating as the GI Index is, it would not be a good idea to swap one set of restrictive numbers (ie. calories) for another" (14). Instead, women should concentrate on eating a well-balanced diet, using the GI index to identify high GI foods that should be eaten in moderation. It may be useful for women with PCOS to visit a qualified dietician for advice on the most appropriate eating plan. As with any weight management strategy, exercise must be combined with changes in eating habits for effective weight loss. Participating in regular exercise not only helps women lose weight but also improves their sense of well-being. Symptoms like acne and hirsutism are often initially treated with a low dose oral contraceptive pill. The pill helps reduce androgen levels and also provides a regular withdrawal bleed, reducing the chance of endometrial hyperplasia. Some oral contraceptive pills also contain a substance called cyproterone acetate which acts as an anti-androgen. If hirsutism does not improve with oral contraceptive use, cyproterone acetate can be given alone in higher doses. Side effects associated with cyproterone acetate include diminished libido, tiredness and weight gain. Another anti-androgen drug, spironolactone, is also used in the treatment of acne and hirsutism. Both cyproterone acetate and spironolactone can only be used by women not trying to conceive as they can cause birth defects. Drug therapy for acne will show benefits within a few months, but for hirsutism improvements take from three to six months with maximum benefits not seen until up to a year (15). Cosmetic therapies such as electrolysis and laser treatment can be used in conjunction with drug therapies to reduce unwanted hair growth. More recent treatments for PCOS have focused on insulin-lowering drugs that are used to treat Type 2 diabetes. These drugs improve the body’s sensitivity to insulin and, therefore, stop the overproduction of insulin associated with insulin resistance (16). The lowering of insulin levels in women with PCOS, in turn, can also reduce androgen levels and improve associated symptoms. While there are a number of insulin-lowering drugs available, the drug involved in most studies involving PCOS is metformin. The use of metformin in the treatment of PCOS is yet to be examined in large scale trials but a number of small scale studies have demonstrated a reduction of androgen and insulin levels and improvements in menstrual regularity and ovulation rates (17). A review of the use of insulin-lowering drugs in the treatment of PCOS conducted last year concluded that "before these drugs can be recommended as first-line therapy for women, longer term clinical trials are needed to compare their safety and efficacy with other established therapies, such as oral contraceptive pills and antiandrogens" (18). In Australia a review commissioned by the Endocrine Society of Australia, the Australian Diabetes Society and the Australasian Paediatric Endocrine Group into the use of metformin for PCOS advised that: "Given the present lack of long-term safety data and demonstrable efficacy in large number of patients, we recommend that metformin use be supervised by an endocrinologist or physician with expertise in the area. Ideally, further research should be encouraged so that outcomes can be scruntinised and regulatory issues can be carefully addressed" (19). The review also included a summary of recommendations for the use of metformin for different symptoms of PCOS. Some women find that complementary medicine can help relieve the symptoms associated with PCOS. A small study investigating the use of electro-acupuncture in women with PCOS, for example, found the treatment induced ovulation in one third of the study group (20). Other complementary therapies that may be useful in regulating hormonal levels include herbal medicine, aromatherapy and homeopathy. Women wishing to use complementary medicine for PCOS should consult a qualified practitioner who can advise on the appropriate course of treatment. It is important for women to disclose any use of complementary medicine to their medical practitioner as it may interact with conventional treatments like drug therapy. Women may also find it helpful to join a support group for PCOS. Support groups provide current and specific information and allow women to share their experiences. Being able to talk to someone who has similar problems can help reduce women’s feelings of isolation. The Polycystic Ovarian Syndrome Association of Australia (contact details below) aims to promote "research, understanding and awareness of PCOS, as well as to serve as a support system that provides accurate information to women with this syndrome" (21). As well as providing a variety of information on the topic with an Australian focus, the Association facilitates the PCOS Australian E-mail List. To subscribe to the list, send an email to:pcos-australia-subscribe@yahoogroups.com
References
Further help and information from Women's Health Queensland WideHealth Information Line: Library: Website: Further information
The Polycystic Ovarian Syndrome Association of Australia (POSAA) This article was written by Kirsten Braun and reviewed by the Editorial Committee for Health Journey, Vol II 2001. Please note that this article is an archive. While every effort was made to ensure the information was accurate at the time of publication, the article has not been updated since this time. Last Modified: June 1, 2001 |
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