Irregular menstrual periods, weight gain, increased facial, chest or abdominal hair. Sound like you or someone you know? Polycystic Ovarian Syndrome is a relatively common and very misunderstood problem responsible, many times, for these signs and symptoms.
Polycystic Ovarian Syndrome (PCOS) was initially identified in 1935 and at that time was called Stein-Leventhal Syndrome. These women were noted to have months with no menstrual periods, increased body hair, weight gain, enlargement of the ovaries and often infertility. Because of the multiple cysts seen on the ovaries, the treatment of choice at that time was surgery with what is called wedge resection of the ovaries, taking a pie-shaped piece out. This seemed to increase the woman’s chances of becoming pregnant.
We now know PCOS is a problem of hormone imbalance. In a normal cycle, which typically lasts 28 days, the first two weeks are dominated by the hormone estrogen. On about day 14, ovulation occurs and at that time the hormone progesterone rises and becomes the dominant hormone. If ovulation does not occur, a couple of things are out of sync.
First of all, the ovaries normally develop small cysts as the follicles grow in preparation for ovulation. These follicles are the ripening eggs and usually the one that matures the most is the one that is released at ovulation (sometimes two are released which is how fraternal twins come about). If the egg is not released, a small cyst is left on the ovary. If this occurs month after month, the ovary contains many cysts hence the term polycystic.
Because progesterone is the dominant hormone after ovulation, if ovulation does not occur, progesterone is not made. Instead, the woman continues to make estrogen “unopposed” by progesterone. Estrogen is the hormone that causes growth. This growth includes the lining of the uterus. When uncheck by progesterone which stops the growth, the lining becomes thicker and thicker. It is not shed in a cyclical manner as usually occurs with the menstrual period and often, instead, eventually starts to break off resulting in prolonged, unpredictable bleeding.
Testosterone is made in greatest amounts at the time prior to ovulation. If, again ovulation does not happen, the testosterone level remains high resulting in hair growth on the face, chest and abdomen.
The diagnosis is not always cut and dry as there are varying degrees in which any one of these signs and symptoms may manifest themselves. A woman may have irregular menses but no increase in body hair. Another may have irregular periods with body hair and weight gain without the appearance of cysts on the ovaries at the time of ultrasound. We typically make the diagnosis by putting all of the information together, and that includes blood tests to check hormone levels. Most women say these symptoms first appeared when they were in their late teens.
Treatment depends on the woman’s signs and symptoms and whether or not she is interested in becoming pregnant.
A younger woman in her late teens or early twenties who is not interested in pregnancy may benefit from the use of oral contraceptives. They will effectively decrease the level of active testosterone, regulate the menstrual period and provide contraception.
A woman is trying to become pregnant may need progesterone for a week every month to bring on her menstrual period then a medication to help her ovulate as this is the bases of the problem.
It is possible (though not typical) that a woman may require surgery because one of the ovarian cysts becomes large enough to be concerning.
In any case, diagnosis and treatment are necessary because years of growing the lining of the uterus without shedding it regularly increases the risk of uterine cancer. In addition, there is an association between PCOS and diabetes. Obesity increases this risk and when the patient is overweight, weight loss is strongly recommended. We will often also treat with a medication used for diabetics if there appears to be insulin resistance. PCOS, obesity and insulin resistance are all associated with metabolic syndrome but we will talk more about next time.