Rx for Change: Polycystic Ovary Syndrome (PCOS)

By Adriane Fugh-Berman, MD and Charlea T. Massion, MD 

Polycystic Ovary Syndrome (PCOS). PCOS is another name for “chronic oligoanovulation”—irregular or absent ovulation resulting in  irregular or absent menstruation. PCOS may be associated with ovaries that have multiple cysts; hyperandrogenism (increased DHEA and/or testosterone); excessive facial or body hair (hirsuitism); acne; and weight gain. Diabetes, high blood pressure, and uterine cancer are associated with the condition, but it bears noting that obesity is also associated with these conditions even in women without PCOS.

PCOS is a common diagnosis in reproductive-age women, but is far more common in younger women; the prevalence of PCOS signs and symptoms drops drastically after age 25. PCOS may resolve over time, and probably should not be diagnosed in adolescents, since they have irregular periods and their ovaries often appear to be cystic on sonograms.

Several different criteria exist for diagnosing PCOS, none of which actually require ovaries to have cysts (for this reason, some have suggested changing the condition’s name). The National Institute of Health (NIH) criteria require anovulation (no ovulation) or oligoovulation (rare ovulation) plus clinical or biochemical signs of hyperandrogenism. The Rotterdam criteria require any two of the following three conditions for diagnosis: anovulation/oligoovulation, hyperandrogenism, and polycystic ovaries revealed by sonogram. The Rotterdam criteria are the standard diagnosis criteria, and have substantially increased the number of women eligible for a PCOS diagnosis.  

It doesn’t really matter what it’s called, though, because different approaches are needed to address different concerns.

Hirsutism associated with excess androgens refers to excess “midline” hair, meaning facial hair (mustache or beard) or hair on the chest or abdomen. This type of hairiness can be treated with oral contraceptives or spironolactone. (Hairiness of the arms and legs is mainly genetic and is not considered part of PCOS.)  

Anovulation/oligoovulation can be addressed by weight loss in women who are above a healthy body mass index (BMI). (By the way, being underweight can also cause ovulation to cease.) For women with PCOS who are not overweight, not ovulating, but don’t want to get pregnant, hormonal contraception can serve a dual purpose; besides being effective birth control, oral contraceptives, periodic progestin therapy, or a progestin-releasing IUD will reduce the risk of developing uterine cancer. For women who want to get pregnant, ovulation-inducing drugs are available.

Diabetes is another concern, and women with chronic oligoanovulation should be regularly tested for diabetes. Obesity increases insulin resistance, which many women with PCOS have. Metformin, a diabetes drug that sensitizes the body to insulin, may be helpful for women with impaired glucose tolerance, although it is unclear whether the drug fosters health benefits in the long term.

Another PCOS treatment is inositol, a natural sugar-like constituent of the body; as a dietary supplement, inositol is common in foods. Inositol may be helpful for many PCOS signs and symptoms; studies of taking 2,000 mg of inositol twice daily show decreased androgen levels, restoration of ovulation, and weight loss. A meta-analysis of six studies comparing the insulin-sensitizing effects of metformin with myo-inositol found similar effects on insulin levels, testosterone levels, and BMI. One study found that taking 1,500 mg of inositol twice a day was as effective as metformin in insulin sensitization and normalization of the menstrual cycle. It is unclear whether inositol improves the chances of conception among subfertile women with PCOS who are trying to conceive.

Most inositol studies have mainly been done with myo-inositol, which the body transforms into inositol triphosphate, and which regulates insulin and hormones affecting the thyroid and ovaries.  Some researchers recommend combining myo-inositol with d-chiro inositol in a 40:1 ratio.Tessa Copp and other researchers at the University of Sydney point out that, while troublesome symptoms should be treated, giving irregularly ovulating women a disease label may not be helpful. Women diagnosed as having PCOS have higher rates of mood disorders, eating disorders, poor self-esteem, and less satisfying sex lives. While proponents of the diagnosis would attribute these symptoms to the “disease,” it may be that the diagnosis itself has negative consequences.