Polycystic Ovary Syndrome

As two of the leading experts on PCOS, Doctors John Frattarelli and Anatte Karmon have evaluated and treated many women in Hawaii and elsewhere for Polycystic Ovary Syndrome (PCOS) associated with infertility. They have given several invited lectures detailing the current research and treatment options regarding polycystic ovary syndrome.

Definition

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder, which affects up to 6-10% of premenopausal women. Features include a lack of regular ovulation and excessive production of androgens (male hormones such as testosterone). Symptoms vary but can include multiple, small cysts (follicles) of the ovaries, irregular or absent periods, excessive body hair growth, difficulty with weight gain and infertility.

Diagnosis: (made by a combination of these)

  • Hyperandrogenism –elevated androgens (male hormones). This can be detected clinically by acne, abnormal hair growth on face, arms, back, legs, etc or by elevated laboratory values.
  • Abnormal menstrual cycles resulting in failure to ovulate. This can be short menstrual cycles (<21 days), long menstrual cycles (>35 days), irregular menstrual cycles or absent menstrual cycles.
  • Ultrasound of the ovaries – many small (<10 mm) follicles seen.

Features of PCOS:

  • Often appears in the teens or 20’s or after a period of significant weight gain.
  • Often associated with insulin resistance; a combination of high blood insulin levels and insulin-hypersensitive ovaries results in the overproduction of (male hormone) testosterone, thus preventing ovulation. Insulin resistant women often have an “apple shape” where fat is deposited around the middle and patches of darkened thickened skin called “acanthosis nigricans” in the groin, armpit and skinfolds.
  • When women with PCOS become pregnant, they may be at increased risk for first trimester miscarriage and for the development of gestational (pregnancy induced) diabetes.
  • Elevated levels of male hormones in women with PCOS cause excessive hair growth on the face, chest, and abdomen, the development of acne, hair loss, and weight gain.
  • Obesity can worsen PCOS because it enhances the abnormal estrogen and androgen production associated with PCOS.
  • PCOS can increase a woman’s risk for the development of adult onset diabetes, elevated cholesterol and triglycerides, cardiovascular problems, endometrial cancer. Untreated, the lifetime risk of heart attack in PCOS may be as high as 7X normal.
  • A family history of diabetes, weight problems, infertility or abnormal hair growth.

Treatment

  • Ovulation induction – The most common drug used to induce ovulation in women with PCOS is clomiphene citrate (Clomid®). Four out of five women with PCOS do ovulate using clomiphene, but only one in three will actually become pregnant. Injectable fertility drugs are about 90% successful over 6 cycles in producing pregnancy in the absence of any other fertility problems. These treatments can be combined with intrauterine insemination or timed intercourse. If these treatments both fail, IVF is usually considered.
  • If elevated insulin levels are found, medications to lower the insulin levels can be used, such as Glucophage/Metformin.
  • Dietary changes – a diet (any diet) and exercise can help with weight loss in women with PCOS; weight loss lowers insulin levels, reduces risk of cardiovascular disease and diabetes.
  • A laparoscopic surgery called ovarian drilling is a surgical procedure that can result in the resumption of regular ovulatory function.
  • Oral contraceptives and cyclic progestin (provera) – For women not actively trying to conceive controlled dosage of hormones regulates cycles; allows the endometrial lining to be shed every four weeks; reduces endometrial cancer risk.
  • Anti-androgens – can block the effects of androgens; high doses can reduce unwanted hair growth and acne. These cannot be used if you are trying to conceive.
  • Electrolysis/Laser treatments – can decrease or eliminate unwanted hair growth.
  • Insulin-lowering drugs/Insulin-sensitizing drugs – lowered insulin levels reduce testosterone production; can reduce unwanted hair growth, acne, obesity, hair loss, cardiovascular risk. These drugs may also significantly increase the effectiveness of clomid in inducing ovulation and some preliminary studies suggest metformin may decrease the risk of first trimester miscarriage in insulin resistant women.
  • Exercise, particularly resistance-type training such as weight training can lower insulin resistance.

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