Polycystic Ovary Syndrome (PCOS)

What is PCOS?

Polycystic Ovary Syndrome (PCOS) is a condition characterized by:

• Polycystic ovaries (multiple tiny ovarian cysts) easily recognized by ultrasound imaging
• Lack of normal ovulation (anovulation)
• Hirsutism, acne oily skin complexion caused by elevated levels of male hormones (androgens).
• Obesity and insulin resistance (affecting about 50% of women with PCOS). High insulin level (insulin resistance) can trigger excess male hormone production by the ovaries, interfere with normal egg production and cause infertility.

How is PCOS Diagnosed?

Polycystic ovary syndrome (PCOS) is typically diagnosed through a combination of clinical symptoms, medical history, and various diagnostic tests. 

PCOS Symptoms

During your first appointment, our fertility specialists will review your current and past symptoms. Many patients with polycystic ovary syndrome (PCOS) have infrequent or no periods, obesity and increased facial hair or acne.

PCOS Ultrasounds

If a diagnosis is not reached from symptoms alone, a vaginal ultrasound can be performed. Patients with polycystic ovary syndrome (PCOS) typically have enlarged ovaries with multiple tiny cysts around the periphery of the ovary arranged in “pearl necklace” formation.

PCOS Blood Tests

Hormone blood tests, such as FSH, LH, E2 on the third day of your menstrual cycle, can also be used to diagnose polycystic ovary syndrome (PCOS). Other frequently ordered blood tests include prolactin, TSH, total and free testosterone, DHEAS, fasting blood sugar and insulin levels. Elevated levels of androgens and LH are common indicators of PCOS.

Medical Risks Associated With PCOS

Polycystic ovary syndrome (PCOS) is a complex hormonal disorder that can lead to various medical risks and health complications. The severity and specific risks associated with PCOS can vary among individuals and will be discussed with you on an individualized basis. Some common medical risks associated with polycystic ovary syndrome (PCOS) are:

• Infertility (ovulation disorder)
• Bleeding problems
• Increased facial hair growth (hirsutism) and acne (due to increased male hormone levels)
• Increased risk of uterine and possibly breast cancer
• Increased risk of obesity
• Untreated women with PCOS, especially those with insulin resistance, have three times the risk of diabetes and seven times the risk of heart disease compared with women without PCOS. High insulin levels can stimulate cell growth and may accelerate the growth of cancer cells, which have increased numbers of insulin receptors.
• High insulin also elevates “bad” cholesterol levels and increases the risk of blockage of arteries and cardiovascular disease.

How does insulin resistance relate to PCOS?

Insulin resistance is increased in women who are overweight and non-exercisers. While there is no real good test for insulin resistance, your doctor may order a fasting blood sugar and insulin levels, triglycerides, HDL cholesterol and measure your blood pressure. If two or more tests are abnormal, your doctor may suggest that you are insulin resistant.

Insulin resistance is a significant factor closely associated with Polycystic Ovary Syndrome (PCOS). PCOS is a hormonal disorder that affects the ovaries and can lead to various symptoms such as irregular menstrual cycles, ovarian cysts, and hormonal imbalances. Insulin resistance refers to a condition where the body’s cells do not respond effectively to insulin, a hormone that regulates blood sugar levels.

In the context of PCOS, insulin resistance plays a key role in the development and progression of the syndrome. Here’s how insulin resistance relates to PCOS:

Hormonal Imbalance: Insulin resistance can trigger an increase in insulin levels in the body. Elevated insulin levels contribute to the production of androgens, which are male hormones that women also have in smaller amounts. The excess androgens can disrupt the normal balance of hormones in the body, leading to symptoms like acne, excessive hair growth (hirsutism), and irregular menstrual cycles.

Ovulatory Dysfunction: Insulin resistance can impact the ovaries’ ability to release eggs regularly. Ovulatory dysfunction is a hallmark of PCOS, leading to irregular or absent menstrual cycles and difficulties in achieving pregnancy.

Weight Gain: Insulin resistance can make it more challenging to manage weight. Many women with PCOS experience weight gain or find it harder to lose weight, which can exacerbate insulin resistance and hormonal imbalances.

Metabolic Syndrome: Insulin resistance is a component of metabolic syndrome, a cluster of conditions that increase the risk of heart disease, stroke, and type 2 diabetes. Women with PCOS have a higher likelihood of developing metabolic syndrome due to insulin resistance.

Long-Term Health Risks: Insulin resistance and the associated hormonal imbalances in PCOS can have long-term health implications. Women with PCOS are at a higher risk of developing type 2 diabetes, cardiovascular diseases, and other metabolic issues.

Managing insulin resistance is an essential part of treating PCOS. Lifestyle changes such as a balanced diet, regular exercise, and maintaining a healthy weight can improve insulin sensitivity and help manage the symptoms of PCOS. In some cases, medication, including insulin-sensitizing drugs like metformin, may be prescribed to address insulin resistance and its impact on PCOS. Consulting a healthcare provider, particularly a reproductive endocrinologist, is crucial for accurate diagnosis and tailored management of both insulin resistance and PCOS.

Treatment of PCOS

In young women who do not wish to be pregnant, treatment most often involves regulation of the menstrual cycle utilizing oral contraceptive therapy in combination with testosterone blocking agents such as Spironolactone (Aldactone). If facial hirsutism or acne is a problem, your physician may also recommend using an insulin sensitizing agent such as Metformin as a first-line therapy. Studies have shown that Metformin treatment can decrease male hormone levels, reduce weight and resume spontaneous ovulation. In addition, anti-insulin medications may also lower the risk for heart disease and cancer by lowering blood insulin level.

Which treatment is right for me if I plan to conceive?

There are a variety of treatment options for you to consider. Our fertility specialists will work with you to find the treatment right for you. Some of the most common treatment options are: 

Weight Loss

Interestingly, studies have demonstrated that even only a 5-10% weight-loss can result in lower male hormone levels and resumption of normal ovulation.

Ovulation Inducing Medications

• Letrozole: Letrozole is often considered the first line of defense for inducing ovulation in individuals with ovulatory disorders. Letrozole’s ability to suppress estrogen levels leads to an increase in the production of follicle-stimulating hormone (FSH) from the pituitary gland. This FSH surge promotes the growth and maturation of ovarian follicles, ultimately leading to the release of a mature egg during ovulation. Letrozole’s effectiveness in stimulating ovulation has made it a promising choice for women with conditions like polycystic ovary syndrome (PCOS) or irregular menstrual cycles, enhancing their chances of successful conception when used under the guidance of fertility specialists.
• Clomiphene Citrate: Clomiphene Citrate tablets are given by mouth (Letrozole, Clomid, and Serophene); they work by stimulating the pituitary gland to release follicle stimulating hormone (FSH), which regulates the development of your eggs. Most often, 50-100 milligrams tablets are taken daily for five days. Development of the eggs can be monitored by ultrasound or detected by over-the-counter ovulation predictor tests. Most patients who respond to this treatment will do so with lower dosage although some patients require a daily dose to 150 mg for five days.
• Gonadotropins: Patients who do not respond to this therapy are referred to as Clomiphene-resistant, meaning they do not respond to this therapy for three cycles at a maximum dosage. Such patients often require injectable hormones (gonadotropins) to induce ovulation.
• Metformin: PCOS patients may benefit from the addition of insulin sensitizing agent (Metformin) to either Clomid or injectable hormone therapy. It is important to note that Metformin does not increase live birth rates and is restricted for use only with patients who have glucose intolerance.

I do not want to conceive, what are my options to treat PCOS?

• Testosterone blocking medications: Facial hair may be caused by elevated male hormones. Effective therapy is, therefore, directed towards blocking the male hormone from reaching the hair follicle or by reducing the amount of active male hormone in the bloodstream. One commonly used androgen-receptor antagonist is Spironolactone (Aldactone) given at a daily dose of 100-200 milligrams. Another medication used to treat excessive hair growth is Finasteride given at a dose of 5 mg daily.
• Oral contraceptives: Oral contraceptives are often given together with testosterone blocking medications because they provide contraception and suppress ovarian male hormone production. Several months of medical therapy are needed before you’ll see a significant improvement in symptoms.
• Weight loss and hair removal: Medical therapy is best utilized in conjunction with weight loss and mechanical therapy such as electrolysis and laser for permanent hair removal.