Polycystic Ovary Syndrome (PCOS)

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November/December 2007 Women’s Health Activist Newsletter

By Kiesha McCurtis

A complex condition of various forms and unknown cause, Polycystic Ovary Syndrome (PCOS) is a condition that is frequently misdiagnosed. PCOS is a reproductive endocrine disorder in which a woman’s ovaries produce excessive amounts of “male” hormones (androgens) such as testosterone. PCOS affects about five percent of U.S. women and is a common cause of infertility, menstrual irregularity, and excessive hair growth.1 This underappreciated condition is the most common cause of female infertility in the U.S.2

PCOS interferes with a woman’s hormones and disrupts the normal process of menstruation. At birth, every woman’s ovaries contain thousands of eggs, each of which is surrounded by cells that develop into follicles every month. (A follicle is a small group of cells with a cavity inside; an ovarian follicle contains the egg). Once a woman starts menstruating, each month a follicle grows and releases an egg for fertilization. With PCOS, however, this process is interrupted and one essential hormone is released in above-normal amounts.

PCOS disrupts the balance of both follicle-stimulating hormone (FSH, the hormone that causes the follicle and egg to develop) and luteinizing hormone (LH, the hormone that causes the follicle to break and release the egg). This hormonal imbalance causes the woman’s body to create higher-than-normal levels of androgens (which women normally produce in only very small amounts). Extraordinarily high LH hormonal levels block both egg growth and ovulation. Since the follicle and egg do not develop properly, the woman’s egg does not break out of the follicle or travel through the fallopian tubes for fertilization or stimulation of a menstrual period. Instead, the undeveloped follicle forms a small ovarian cyst. These multiple, tiny ovarian cysts were once considered to be PCOS’ main characteristic and gave the disorder its name.

PCOS’ cause is unknown. It was first described in 1935 by Drs. Stein and Leventhal as a condition due to “hormonal stimulation”; over 70 years later, it is still not clear what causes the syndrome. Although the disease tends to run in families, little is known about how PCOS passes from one generation to another. Increasingly, it is thought that PCOS is caused by a number of underlying genetic interactions and predispositions and that environmental issues – including diet, exercise, pollution, and stress -- play an important role in PCOS’ development.

Common Symptoms
A woman’s hormonal system is sensitive, so any slight change in hormone levels that lasts for an extended period of time can wreak noticeable effects on the body. PCOS is different in every woman – it may begin around puberty or it may not become noticeable until a woman is in her twenties or thirties. Women are affected in different ways, but common symptoms include: irregular menstrual periods or a complete lack of a period altogether; excess hair growth on the face, breasts, around the nipples, the back, abdomen, arms and/or legs; obesity; acne; or infertility.

Other physical signs that help physicians diagnose PCOS include hormone imbalances; insulin resistance, with an increased risk of developing diabetes; and enlarged ovaries with benign cysts, which are often visible on an ultrasound. It can be hard for women to tell that these disparate symptoms are related. “I thought I had four or five different things going on,” said Patricia Barfield Hicks, 33, of Lexington, Ky. “The weight gain, the infertility. It was such a relief to finally find out it’s all tied together.”3

The Role of Lifestyle and Environment
Stress, pollution, and diet all affect the course of PCOS although it is not yet known exactly how they influence the disease. Under stress, the body responds by increasing hormone production, including production of cortisol and adrenaline, the “fight or flight” hormones. Cortisol can encourage weight gain, irregular periods, acne, excess body hair, high blood pressure, and diabetes – exacerbating PCOS symptoms.4

Environmental pollution and food processing expose people to various chemicals and pollutants including chemicals from industrial pollution, like dioxins and PCBs; plastic components, like phthalates; and food additives, like sodium. All of these are anti-nutrients that mimic hormones and several have been deemed “endocrine disruptors”. It is likely that these endocrine disruptors affect estrogen and steroid receptors and, in turn, directly influence PCOS development.4 Women with PCOS (or a genetic predisposition for PCOS) should try to avoid endocrine-disrupting chemicals – although eschewing pollution and chemicals from food and the environment is easier said than done.

Over the last century, the U.S. diet has changed enormously and, as a result of modern processing, food today has more calories and less nutritional value. Many scientists argue that highly refined and processed foods that are low in nutritional value and high in additives are harmful to health. This is particularly true for women with PCOS because excessive caloric intake causes weight gain that exacerbates their symptoms.

Other problems linked to PCOS
The hormonal imbalance underlying this syndrome often causes other medical issues, as well. PCOS is related to an increased risk of diabetes, heart disease, and endometrial cancer. These serious risks are often very different from the symptoms for which a woman might initially seek her doctor’s attention (for example, a woman might seek care for irregular periods, but discover with a full medical work-up that this results from PCOS and is accompanied by more serious risks than she had suspected). Many women seek care from a dermatologist for facial hair, or from a nutritionist for weight gain. Says Suzanne Cerquone, 30, of Philadelphia: “Because the majority of the symptoms are cosmetic, no one considers it a serious thing, but the underlying thing is[,] it’s not just cosmetic.”

Insulin Resistance and Diabetes: Diabetes is a disease in which the body cannot properly process insulin, the hormone the body produces in order to transfer food sugars into energy. Diabetes is a chronic condition and has no cure. For individuals with insulin resistance, the average amount of insulin is not sufficient enough to complete this job. Women with PCOS have an impaired ability to use insulin effectively, which can result in high blood sugar levels and diabetes. Women with PCOS who are insulin resistant are seven times more likely to develop adult-onset diabetes than the rest of the population.7 Making healthy diet decisions, exercising regularly, and maintaining a healthy weight are all important steps for controlling adult-onset diabetes.

Heart Disease: Women with PCOS have a high risk of developing heart disease, partly because they also tend to have more risk factors associated with heart disease. For example, women with PCOS have a higher risk of insulin resistance and diabetes and a greater tendency to be overweight or obese. Having PCOS increases a woman’s risk of having a heart attack by seven-fold, compared to the general population.8

Endometrial Cancer: Since most women with PCOS do not have a normal menstrual cycle, their uterine lining is not shed and replaced each month. Instead, old cells build up within the uterus; the more time that passes without a period, the more of a buildup occurs on the uterine walls. Sometimes, this buildup can cause an overgrowth of the endometrium, which can be a precursor to cancer. However, women with PCOS who ovulate and have regular periods do not have an increased risk of endometrial cancer.3

Treatment Options
Generally, treatment depends on how PCOS affects the individual woman, as personal goals may vary when considering medical therapy. Traditional treatments for PCOS have been aimed toward individual symptoms. For some women, getting pregnant may be the ultimate goal; for others, addressing heart disease and diabetes risk may be of particular importance. There are currently no cures for PCOS, but with education and treatment, the risks can be minimized.

Both weight loss and exercise have been shown to lower insulin levels, in turn leading to a decrease in androgens and a general improvement of symptoms.9 Diet and exercise have been proven to improve the frequency of ovulation, improve fertility, and lower the risk of heart disease and diabetes.1 Medical treatments to restore ovulation or target insulin resistance are commonly prescribed for women with PCOS. These treatments may help reverse some of the problems associated with the syndrome, but it is not known whether these therapies can stop PCOS’ long-term effects.

Insulin Sensitizers: Insulin sensitizers are intended to help the body effectively process insulin again. These types of medications are approved for treatment of adult-onset diabetes, but have also been shown to successfully treat women with PCOS who have insulin resistance. As insulin levels normalize, the ovaries resume normal function and many PCOS symptoms diminish. Insulin sensitizers may help restore menstrual cycles and alleviate excessive hair growth, acne, and weight gain. Metaphormin (brand name Glucophage) is an insulin sensitizer that seems to alleviate PCOS symptoms for many women.3 But, because this drug is not approved by the FDA for treatment of PCOS, getting health insurance coverage for insulin sensitizers for a woman who does not have diabetes is difficult, at best.

Oral Contraceptives: Oral contraceptives make periods more regular, which in turn causes a women to shed the uterine lining regularly, thereby reducing her risk of endometrial cancer. Oral contraceptives also lower androgen levels in the bloodstream, which helps to decrease excessive growth of facial hair and acne. The potential side effects for oral contraceptives as a form of PCOS treatment remain the same (spotting, breast tenderness, weight gain or water retention, spotty darkening of the skin, mild headaches, and/or mood changes, including decreased sex drive).10

Androgen Blockers: Medications that are specifically targeted at countering the effects of excess androgen block the effects of androgen and reduce new androgen production. This type of treatment (as with the drug Spironolactone [Aldactone]) is particularly effective in reducing excessive hair growth. Spironolactone was first used to treat high blood pressure, but has been shown to reduce the impact of male hormones on hair growth in women.11 It has, however, caused tumors in laboratory animals so women should discuss with their physician the risks and benefits of using it for PCOS.12 The prescription cream Eflornithine (Vaniqa) is sometimes prescribed in addition, to slow facial hair growth in women; this drug has been shown to be effective for about one-third of the women who have used it.2

Fertility Drugs: Drugs such as Clomiphene Citrate (Clomid) are frequently prescribed to trigger egg growth and ovulation for women seeking to get pregnant. Clomiphene Citrate is an oral anti-estrogen medication taken in the first part of the menstrual cycle. If Clomiphene is not effective, Gonadotropins -- FSH and LH medications – may help. Because many women with PCOS have elevated LH levels, a doctor may recommend treatment with FSH alone. With Clomiphene or Gonadotropins, her risk of having multiple births (e.g., twins or triplets) is increased.2 Surgical techniques that make small holes in one or both ovaries are sometimes successful in restoring ovulation as well, although not always permanently.

Improvements in diagnosis and treatment since the condition was first recognized in 1935 have made PCOS a manageable condition for many women. Although its exact underlying cause still remains a mystery, research on the condition continues to grow with strong evidence that PCOS is likely a genetic disorder. The increased attention that PCOS has gained over the past decade has influenced research projects to explore genetic interactions and predispositions, environmental issues, and the effects of new treatments.

Resources:
 

 Kiesha McCurtis is the NWHN Health Information Coordinator.

REFERENCES:

1. American Society for Reproductive Medicine (ASRM), “Polycystic Ovary Syndrome,” Birmingham, AL: ASRM. February 2005, page 1. Available online at: http://www.asrm.org/Patients/FactSheets/PCOS.pdf. Accessed November 13, 2007.

2. Mayo Clinic, “Polycystic Ovary Syndrome,” Scottsdale, AZ: Mayo Clinic, 2007, page 1. Available online at: http://www.mayoclinic.com/health/polycystic-ovary-syndrome/DS00423. Accessed November 13, 2007.

3. Epstein, Randy Hutter, “Infertility, Excess Hair. Unexplained Weight Gain; Doctors are linking these symptoms to a hormonal imbalance that has severe lifelong consequences. New treatments may provide some relief,” The Washington Post, January 18, 2000, p.Z12.

4. Harris C, PCOS: A Women’s Guide, London: HarperCollins Publishers Ltd., 2000; 45-64.

5. Boss, Angela and Evelina Weidman Sterling, Living with PCOS, Omaha: Addicus Books, 2001; 68.

6. Epstein, Randy Hutter, “Infertility, Excess Hair. Unexplained Weight Gain; Doctors are linking these symptoms to a hormonal imbalance that has severe lifelong consequences. New treatments may provide some relief,” The Washington Post, January 18, 2000, p.Z12.

7. Ehrmann DA, Rosenfield RL, “Detection of functional ovarian hyperandrogenism in women with androgen excess,” NEJM 1992; 337:157-62.

8.Carey AH, Chan KL, “Evidence for a single gene effect in polycystic ovaries and premature male pattern baldness,” Clin Endocrinol 1993; 38:653-8.

9. McKittrick, M, “Diet and Polycystic Ovary Syndrome,” Nutrition Today, March-April 2002 37(2).

10. The Boston Women’s Health Book Collective. Our Bodies, Ourselves, Simon & Schuster, 2005; 349.

11. National Women’s Health Information Center. “Polycystic Ovary Syndrome,” Washington, D.C.:U.S. Department of Health and Human Services, Office on Women’s Health. Accessed: Nov.13, 2007. Available online: http://womenshealth.gov/faq/pcos.htm#i.

12. Consumer Reports. “Spironolactone,” May 2007. Available online: http://www.consumerreports.org/health/drug-reports/spironolactone.htm?resultPageIndex=1&resultIndex=0. Accessed December 6, 2007.

 

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