Polycystic Ovary Syndrome

What Is It?

Estrogen and progesterone are the female hormones produced by the ovaries that cause monthly menstrual cycles to occur. However, a third hormone, testosterone, also is produced by the ovaries, usually in small amounts. Testosterone is in a broad class of hormones called androgens, and it is the dominant sex hormone in men.

Between 4% and 7% of women produce too much testosterone in their ovaries. These women have a pattern of symptoms called polycystic ovary syndrome.

When a woman has a high level of androgen hormones in her body, her ovaries continue to develop eggs in follicles, which are fluid-filled pockets. However, she usually is unable to release the eggs from the ovaries, so the ovaries appear to contain many cysts the reason for the term "polycystic" in the name of the disease. Women with this condition may have problems with fertility because ovulation stops or happens only once in a while. When no egg is released, the woman's hormones also don't change levels as they normally should with each monthly cycle. In reaction, the uterus still manufactures an inside lining, but the lining is fragile and can cause irregular bleeding. The lining is not shed all at once as during a normal menstrual period. Because of the abnormal hormone balance, the lining of the uterus is also at a higher risk of developing a cancer.

In women with polycystic ovary syndrome, the androgen hormones also cause other effects. Just as in teenage boys who have high levels of androgens, women with high levels of androgens can have problems with acne and can have increased hair growth in a male pattern such as in the mustache area or on the face.

Recent research has shown that women with polycystic ovary syndrome not only have high levels of androgen hormones but also have high insulin hormone levels. Insulin is produced in higher quantities to compensate for the body's increased resistance to insulin's effects. It is likely, although it has not been proven, that excess insulin is the root of the problem in polycystic ovary syndrome. Excess insulin can cause the body's ovaries to make extra androgen hormones. The high insulin levels cause other significant concerns for women with this disease. They are much more likely to become obese, and they are at a high risk of developing diabetes, high blood pressure, cholesterol problems and heart disease.

No one is certain why insulin resistance occurs. It is thought that polycystic ovary syndrome, like most cases of insulin resistance, is caused by an inherited gene defect. In addition to people with a family history, women with recurrent seizures are more likely to develop polycystic ovary syndrome. This might happen because repeated seizures affect the brain's hypothalamus and pituitary gland, which regulate the production of reproductive hormones.

Symptoms

Polycystic ovary syndrome usually does not cause symptoms before mid-puberty, when the ovaries begin to produce hormones in significant amounts. Women then can have some or all of the following symptoms:

• Menstrual periods that are infrequent, irregular or absent
• Difficulty getting pregnant
• Obesity (in 40% to 50% of women with this condition)
• Acne
• Hair growth in the beard area, upper lip, sideburns, chest, the area around nipples or the lower abdomen along the midline
• Darkened, thickened skin, sometimes appearing similar to velvet, in the armpits
• High blood pressure, high blood sugar or a cholesterol problem

Diagnosis

If your periods are irregular, a pregnancy test should be done.

Specific changes in the growth pattern of your hair or the development of acne may be enough for your doctor to determine that you have a high level of androgen hormones. Blood tests also can detect high androgen levels, and blood tests can confirm that the excess androgen is mostly testosterone, the kind of androgen that is made in the ovary. If a different kind of androgen hormone is elevated, or if testosterone levels are more than moderately elevated, polycystic ovary syndrome may not be the correct diagnosis, and your doctor might choose to do some additional tests to check for problems in your adrenal glands. You also should have a blood test to check the level of prolactin, which is a hormone produced in the brain's pituitary gland. Very high prolactin levels can be caused by a pituitary gland tumor, and this problem can cause symptoms that resemble those of polycystic ovary syndrome.

As long as other causes of your symptoms have been excluded, your doctor will diagnose polycystic ovary syndrome if you have high androgen levels plus infrequent or absent menstrual periods. Many doctors will check the levels of other sex hormones that are affected as a result of this condition, including luteinizing hormone and follicle-stimulating hormone, to be more certain about the diagnosis. Some doctors may choose to look at your ovaries using ultrasound, especially if the ovaries feel enlarged during your pelvic examination. An ultrasound test is likely to show multiple cysts in the ovary, but this test is not necessary for your doctor to make a diagnosis. The test also can be misleading. Some women have all the typical hormone abnormalities of this condition, but their ovaries have not developed cysts. The diagnosis and treatment for these women is no different.

Because of the increased risk of diabetes and heart disease that goes along with this condition, it is very important to have your blood sugar and your cholesterol tested periodically. The American Diabetes Association suggests that people with this condition should have their blood sugar tested every two years.

Expected Duration

This problem begins in puberty and lasts until the ovaries stop producing hormones due to menopause. The insulin resistance, high insulin levels, diabetes risk and heart disease risk usually last throughout life.

Prevention

Because polycystic ovary syndrome probably stems from a hereditary problem in most cases, there is currently no way for most people to prevent it. Our understanding of problems relating to insulin resistance is improving rapidly, and some scientists are hopeful that we eventually will be able to prevent some cases of polycystic ovary syndrome if we can identify and treat insulin resistance in its earliest stages.

Treatment for polycystic ovary disease can prevent complications such as uterine cancer. Because you have an increased risk of heart disease and cholesterol problems if you have this condition, it is very important that you avoid smoking, maintain a healthy exercise regimen and follow a low-cholesterol diet.

If you have epilepsy and you have any features of polycystic ovary syndrome, it may be wise for you to avoid the anti-seizure medicine valproic acid (Depakote, Depakene). This medicine affects the metabolism of some reproductive hormones within the body, and may worsen your symptoms.

Treatment

Weight loss, diet and exercise are recommended for all women with polycystic ovary disease to prevent obesity and to help prevent heart disease and diabetes. Other treatment of polycystic ovary syndrome depends upon your symptoms and whether you want to become pregnant.

If you do not want to become pregnant, it is still important to restore normal menstrual cycles to reduce the risk of cancer in the uterus. This can be accomplished using pill supplements of progesterone for 10 to 14 days each month. Another way to restore menstrual cycles is to take birth control pills that contain both estrogen and progesterone. The estrogen seems to signal the ovaries that they can take a break from producing female sex hormones. In women who are taking birth control pills, the ovaries also decrease their production of androgens. After six months on birth control pills, side effects of hair growth and acne usually show significant improvement.

For women who still have problems with unwanted hair and acne, an anti-androgen medicine can help. The most commonly used anti-androgen medicine is spironolactone (Aldactone), although others are available. Plucking or cosmetic laser treatment (electrolysis) also can be used for hair removal.

It is now possible to help about 75% of women with this condition to become pregnant. Clomiphene citrate (Clomid, Milophene, Serophene), a medicine that assists the ovary to release its eggs, is the main treatment.

Your doctor may prescribe medicines that specifically target insulin resistance. Even if a woman with this syndrome has not developed diabetes, the diabetes medicines that lower insulin resistance metformin (Glucophage), rosiglitazone (Avandia), and pioglitazone (Actos) can decrease testosterone levels, restore normal menstrual cycles and assist with fertility.

All women who have complications of high cholesterol, high blood pressure or diabetes should receive specific counseling and treatment for these conditions.

Although surgery used to be a common treatment for this condition, it is used only rarely now. Removing a section of the ovary with procedures called wedge resection or ovarian drilling can decrease the amount of androgen hormones in the body and temporarily improve symptoms.

When To Call A Professional

If you have any of the symptoms of polycystic ovary syndrome, you should see your health care professional, especially if you have had irregular or absent periods for more than six months.

Prognosis

With treatment, most women's symptoms improve or go away. Women with polycystic ovary syndrome need to pay strict attention throughout their life to ways they can reduce their risks of heart disease and diabetes.

Additional Info

American College of Obstetricians and Gynecologists

P.O. Box 96920

Washington, DC 20090-6920

Phone: (202) 638-5577

http://www.acog.org/