WHAT IS PCOS?
Polycystic ovary syndrome (PCOS) is the most common cause of irregular menses in the United States and affects up to 1 in 10 women. While PCOS can show up in a number of different ways there are clearly defined criteria for how to diagnose PCOS.
PCOS is diagnosed when a person meets 2 out of the 3 Rotterdam criteria, namely:
- Irregular menses
- Clinical or biochemical signs of hyperandrogenism (elevated male hormones).
- Polycystic appearing ovaries
You also need to exclude other common causes of the above symptoms such as thyroid or other hormonal abnormalities among others.
LET’S TALK ABOUT EACH OF THE CRITERIA
WHAT ARE IRREGULAR MENSES?
According to the American College of Obstetrics and Gynecology (ACOG) normal menses (periods) should occur every 24 to 35 days and anything outside of that window is considered irregular. That is the time between the first day of one period and the first day of the next should be between 24 -35 days. It is also normal to have some fluctuation from month to month, for example if one month is 28 days and the next is 31 days, that is still considered normal.
WHAT IS HYPERANDROGENISM?
Hyperandrogenism means elevated levels of male hormone levels, and in PCOS we are specifically referring to testosterone. Women do and should make some testosterone, however in PCOS the testosterone levels can be higher than what is normally seen in women. This is called biochemical hyperandrogenism.
In some cases, testosterone levels are normal but symptoms such as hirsutism (increased male pattern hair growth for example on the chin, neck, chest, abdomen e.t.c), significant acne and male pattern hair loss are present. These are considered clinical signs of hyperandrogenism.
WHAT ARE PCOS APPEARING OVARIES?
We are able to count early eggs on ultrasound by counting follicles (little bubbles each of which contains one microscopic egg). Women with PCOS typically have greater than 12 follicles on each ovary and an ovarian volume greater than 10cm3 on pelvic ultrasound. The name polycystic ovary syndrome is a misnomer because what is actually seen on the ovaries are not cysts but follicles.
The follicle count is the least specific of all the 3 criteria for PCOS because women can have greater than 12 follicles on each ovary, just because they have a good number of eggs and a good ovarian reserve. Therefore in the absence of any other signs of PCOS, having a lot of follicles is a sign of good ovarian reserve.
WHY DOES PCOS MATTER FOR FERTILITY?
As mentioned earlier, irregular cycles are a defining feature of PCOS. Having irregular cycles means that you’re either not ovulating or ovulating infrequently, which makes it difficult to determine when to try for pregnancy.
Ovulation is the process by which the ovary releases a mature egg. Until the egg is released from the ovary, it cannot be fertilized by sperm and pregnancy cannot occur. Therefore, infrequent or absent ovulation means more difficulty getting pregnant.
While it is possible for women with PCOS to conceive without fertility treatment, infrequent periods can make it difficult to determine when to try and because this also means fewer ovulations per year, they have fewer opportunities to try as well.
WHAT TREATMENT OPTIONS ARE AVAILABLE FOR INFERTILITY DUE TO PCOS?
Since the main cause of infertility in women with PCOS is the absence of ovulation, the first step in treating infertility due to PCOS is to induce ovulation with the help of medications. Once we are able to induce ovulation, intercouse is then planned based on time of ovulation.
Ovulation induction in PCOS is usually a two-step process:
- Inducing growth of at least one egg (this appears as a large follicle on ultrasound)
- Triggering ovulation with a trigger injection. In many patients with PCOS, inducing follicle growth is not enough to ensure that the egg is released from the follicle and a trigger shot is recommended.
If pregnancy is not achieved after a few cycles of ovulation induction and timed intercourse, then intrauterine insemination (IUI), a procedure in which sperm is placed directly into the uterus should be added on to each cycle.
In some cases, women with PCOS may need to go through in vitro fertilization (IVF) to achieve pregnancy if ovulation induction combined with IUI is unsuccessful.
DO WOMEN WITH PCOS WHO ARE NOT TRYING TO CONCEIVE NEED TO BE ON CONTRACEPTION?
Yes, because women with PCOS can sometimes ovulate, they need to be on some form of contraception to prevent pregnancy.
Many hormonal contraceptives such as birth control pills and levonorgestrel (progestin) containing IUDs also decrease the risk of endometrial cancer, which women with PCOS are at increased risk for.
IS PCOS IMPORTANT WHEN YOU’RE NOT TRYING TO CONCEIVE?
Yes it is because PCOS affects other aspects of your health.
Women with PCOS are more likely to have diabetes, high blood pressure, obesity, depression and anxiety as well as endometrial cancer. These can have important implications for a woman’s health past her reproductive years and into menopause.
PCOS AND OBESITY
Women with PCOS have an increased risk of obesity. Obesity can also bring about the onset of PCOS symptoms in women with PCOS who previously had no symptoms. Additionally, obesity significantly increases the risk of diabetes, high blood pressure and heart disease in women with PCOS.
It is important to note that obesity on its own can cause irregular periods, and so a complete evaluation needs to be done to determine the true cause of irregular periods in the setting of obesity.
PCOS AND DIABETES
Women with PCOS have an increased risk of diabetes, and this risk continues even after menopause. Eating a healthy diet, exercising regularly and maintaining a healthy BMI all help to reduce the risk of diabetes with PCOS. If you’ve been diagnosed with PCOS, you should consider getting a screening test for diabetes especially if you have a BMI over 25, have a family history of diabetes or have had a previous pregnancy complicated by gestational diabetes.
PCOS AND HIGH BLOOD PRESSURE AND HEART DISEASE
Women with PCOS have an increased risk of high blood pressure and heart disease, both of which increase the risk of a heart attack. These risks are even higher if either obesity or diabetes are also present. Eating a healthy diet, exercising regularly and maintaining a healthy BMI all help to reduce the risk of high blood pressure and heart disease with PCOS.
PCOS AND MENTAL HEALTH
Women with PCOS have higher levels of depression and anxiety. If you have a diagnosis of PCOS and are struggling with either anxiety or depression, please discuss with your physician about getting a referral to a licensed mental health professional.
PCOS AND ENDOMETRIAL CANCER
Due to the irregular periods associated with PCOS, women with PCOS may have an increased risk of endometrial cancer. This risk is directly related to infrequent periods which cause prolonged exposure of the uterine lining to estrogen. The uterine lining is designed to completely shed and regrow each month and when this doesn’t occur, it starts to undergo changes that over time may result in cancer.
Protecting the uterine lining from prolonged estrogen exposure is straightforward and essentially removes the increased risk of uterine cancer. To do this, when you’re not actively trying to conceive you should consider being on some form of hormonal therapy with progesterone to balance out the estrogen. This can be in the form of combined hormonal pills such as birth control pills, progesterone pills for a few days a month or levonorgestrel (progestin) containing IUD.
HOW TO ALLEVIATE THE NEGATIVE EFFECTS OF PCOS
HIRSUTISM AND ACNE
These symptoms are due to the increased activity of testosterone that can be seen in PCOS, even when actual testosterone levels are normal. As a result, the therapeutic goal is the reduction of testosterone levels by decreasing its production, decreasing its availability and decreasing its activity.
The first line of treatment of hirsutism and acne in women with PCOS is birth control pills, not to prevent pregnancy, but to decrease testosterone production and availability. It typically takes at least 6 months before any positive effects from treatment can be appreciated. If birth control pills do not work, you can discuss other treatment options with your provider which will also target testosterone production, availability and activity.
Non-hormonal treatments such as electrolysis and laser hair removal are also available.
DIET AND EXERCISE
A big part of PCOS has to do with the way our bodies produce and respond to insulin in response to carbohydrates, therefore it is not surprising a diet that it low in carbohydrates has been shown to be more effective in decreasing not only glucose and lipid levels (which decreased the risk of diabetes and heart disease), but also in decreasing testosterone levels.
Decreasing glucose and lipid levels decrease the risk of diabetes and heart disease and lower testosterone levels can lead to more regular periods and also improve symptoms such as acne and hirsutism (increased male pattern hair growth on the chin, neck, chest, abdomen e.t.c).
Overall, a healthy lifestyle goes a long way to alleviate the symptoms of PCOS, but in many cases medical intervention is also needed, as a result managing PCOS is a partnership between you and your healthcare provider.
Dr. Deborah Ikhena-Abel
Dr. Ikhena-Abel obtained her medical degree from the Geisel School of Medicine at Dartmouth and completed her residency in OB/GYN at the University of Massachusetts School of Medicine in Worcester, MA. She completed her fellowship in Reproductive Endocrinology and Infertility at Northwestern University. She considers it a privilege to help patients grow their families. Dr. Ikhena-Abel specializes in caring for several women’s health conditions including infertility, fertility preservation, polycystic ovarian syndrome, uterine fibroids, polycystic ovarian syndrome, recurrent pregnancy loss and irregular or absent periods. She is a reviewer for Fertility and Sterility and the Journal of Assisted Reproduction and Genetics. She also serves as an abstract reviewer for the American Society of Reproductive Medicine.
