Polycystic Ovary Syndrome

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) has been renamed to polyendocrine metabolic ovarian syndrome (PMOS).

Estrogen and progesterone are the female hormones produced by the ovaries. The levels of these hormones vary during the monthly menstrual cycle. They are essential to the development of follicles, which are fluid-filled pockets containing an egg that is released each month.

A third hormone, testosterone, also is produced by the ovaries 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 and signs called polyendocrine metabolic ovarian syndrome (PMOS, formerly known as polycystic ovary syndrome or PCOS).

When a woman has a high level or imbalance of androgen hormones such as testosterone in her body, she can be unable to release eggs from their follicles in the ovaries. Since the fluid-filled follicles don’t open and empty, they may stay in the ovary and the ovaries appear to contain multiple small cysts. This was the reason for the prior use of the term "polycystic" in the name of the disease.

In the last several years, it became clear that the older name did not capture the condition's significant effects beyond the ovaries. In fact, women can have PMOS without the presence of ovarian cysts. The new name highlights the reproductive, endocrine, and metabolic consequences of the androgen imbalance.

Women with this condition may have problems with fertility because egg release (ovulation) stops or happens only once in a while.

In addition to the problem of egg release during a monthly cycle, the woman's hormones don't change levels as they normally should. In reaction, the uterus manufactures a fragile inside lining that can cause her to have irregular bleeding. The lining is not shed all at once as during a normal menstrual period.

In women with PMOS, the androgen hormones also cause cosmetic effects. Women with high levels of androgens can have acne and can have increased hair growth in a male pattern such as in the mustache area or on the face.

Commonly, women with PMOS not only have high levels of androgen hormones, but they also have high levels of insulin and resistance to insulin’s effects. The high insulin levels are a marker for other health concerns that occur with this disease.

As is true for anyone with high insulin levels, women with PMOS are more likely to become obese. And they are at a higher risk of developing diabetes, high blood pressure, heart disease, and fatty liver.

Excess insulin may trigger the ovaries to make extra androgen hormones. So insulin resistance — a change in how efficiently you metabolize food calories — may be a trigger for PMOS in some women. However, experts are not sure that insulin is always the root of the problem.

Genetics and the way that some of the body’s glands are programmed (the ovaries, the pituitary gland, and the adrenal gland) also play a role in causing this condition.

Symptoms of PCOS

PMOS usually does not cause symptoms before mid-puberty. When the ovaries begin to produce hormones in significant amounts, 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.

Diagnosing PCOS

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

Changes in the growth pattern of your hair or the development of acne may be an indication that you have an elevated level of androgens, such as testosterone. A blood test can confirm it.

A blood test may also be used 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 PMOS.

Your doctor can make a clinical diagnosis of PMOS if

other causes of typical PMOS symptoms have been excluded

and

your testosterone levels are elevated

and

you have infrequent or absent menstrual periods.

Your doctor is likely to check the levels of other hormones that can be associated with high testosterone or can cause similar symptoms, to be more certain about your diagnosis.

Testosterone can’t be tested reliably if you are currently taking birth control pills.

Your doctor 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. 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 periodic blood sugar tests.

Expected duration of PCOS

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.

Preventing PCOS

There is currently no way for most people to prevent PMOS. 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 PMOS if we can identify and treat insulin resistance in its earliest stages.

Treatment for PMOS can prevent complications, such as a lower risk of endometrial cancer of the uterus. Because you have an increased risk of heart disease if you have this condition, it is very important that you avoid smoking, maintain a healthy exercise regimen, and follow a healthy diet.

If you have epilepsy and you have any features of PMOS, you probably want to take other antiseizure medicines rather than valproic acid (Depakote, Depakene). This medicine affects the metabolism of some reproductive hormones within the body, and may worsen your symptoms.

Treating PCOS

A healthy diet aimed at weight loss if necessary and physical activity with dedicated time for exercise are recommended for all women with PMOS, to prevent obesity and to help prevent heart disease and diabetes. Other treatment of PMOS depends upon your symptoms and whether you want to become pregnant.

Restoring normal menstrual cycles may 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 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.

Your doctor may prescribe diabetes or anti-obesity medicines that reduce insulin resistance, such as GLP-1 agonists (semaglutide, liraglutide, tirzepatide), metformin, and pioglitazone.

It is now possible to help many women with this condition to become pregnant. Letrozole is often the first recommend drug to induce ovulation, which helps the ovary grow and release its eggs. Clomiphene citrate may be another fertility option.

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 periods for more than six months.

Prognosis

With treatment, symptoms may 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.