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Polycystic Ovary Syndrome (PCOS)

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The Facts about Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS), also called Stein-Leventhal Syndrome, is a disorder characterized by irregular, abnormal or absent menstruation; excessive amounts of body hair; excessive body weight and decreased fertility. The syndrome is caused by elevated levels of testosterone and other hormones, which disrupts the normal menstrual cycle. Immature cysts remain on the ovaries, giving them a characteristic “string of pearls” appearance. A faulty response to insulin is also suspected, but does not explain all cases of the syndrome. It’s estimated that this condition affects 6% to 10% of premenopausal women of all races and ethnicities, beginning between puberty and the early 20s.

Symptoms

Irregular Menstruation. The most common symptom of PCOS is irregular menstruation, which can take several forms:

* Oligomenorrhea: 8 or fewer periods per year.
* Polymenorrhea. Too many periods with excessive bleeding, and periods that may stop and start.
* Amenorrhea. No menstrual cycles at all.

Infertility. The three types of menstrual disorders have the same underlying cause: the ovaries don’t release an egg each month. Women with PCOS do not ovulate regularly, and while fertility experts do assist many women with PCOS in becoming pregnant, PCOS may account for as many as half of all cases of infertility.

Hirsutism. Excess hair or coarse, thick hair on the face and arms, legs, abdomen and pubic area are also symptoms of PCOS. Changes in hair are stimulated by the free androgens in the system, present because of the hormonal imbalance.

Thinning hair. Male-pattern hair loss is also related to the excess androgens associated with PCOS.

Skin abnormalities. The skin abnormalities associated with PCOS can take several forms, including skin flaps or small tags of skin in the armpits or neck area, and acanthosis nigricans, which darkens and thickens the skin, usually on the neck or in the underarms or groin. This condition results from excess insulin in the blood stream.

Weight gain. Many women with PCOS experience weight gain, have a high hip to waist ratio (“apple” rather than “pear” shape), and have more than normal difficulty losing weight.

PCOS also has a complex relationship to depression and anxiety. Depression is not considered a symptom of PCOS per se, but the range of physical, cosmetic and physiological symptoms experienced by PCOS sufferers present a suite of underlying causes. In some women, correction of insulin-related problems through diet, exercise and medication help to alleviate depression and anxiety.

Diagnosis
A diagnosis of PCOS is made on the basis of the range of symptoms and on the patient’s menstrual, reproductive and medical history (including any diabetes or insulin-related symptoms), blood tests to determine hormone levels, physical examination and diagnostic ultrasound.

Blood tests, indicate PCOS when the ratio of luteinizing hormone (LH) to Follicular Stimulating Hormone (FSH) is equal to or greater than a 3:1 ratio, and there are elevated levels of androgens including free and total testosterone. Glucose and insulin tests can be used to screen for insulin resistance and type II diabetes. Many women with PCOS have insulin-related problems, and some research indicates that this may be a root of the problem. The blood is also tested for lipids to find the levels of cholesterol and trigylcerides. High levels of LDL (“bad cholesterol”) are common with PCOS, and this suggests that women with PCOS are at higher risk for heart disease.

Ovarian cysts are no longer the basis for a definitive diagnosis of PCOS (it is possible to have polycystic-appearing ovaries without actually having PCOS); many physicians rely on ultrasound imaging to confirm their diagnosis.

Treatment Options
PCOS is can be treated by a family physician or gynecologist, but the patient may also be referred to doctor who specializes in hormonal disorders – an endocrinologist, reproductive endocrinologist or fertility specialist.

Many standard therapies for PCOS treat specific symptoms, but might not address the underlying causes. Oral contraceptives have traditionally been used to regulate menstrual cycles. Anti-androgenic agents such as spironolactone block the effect of androgens (male hormones, including testosterone), and can reduce unwanted hair growth and acne. Assisted reproduction techniques – like oral and injectable medications that stimulate ovulation, and in vitro fertilization – enable women with PCOS to become pregnant.

New treatments aim at the insulin resistance that might be a root cause of PCOS. Many new therapies are designed to lower insulin levels and thus reduce testerone production.

Drug Therapy
New evidence suggests that using medications that lower insulin levels in the blood may be effective in restoring menstruation and reducing some of the health risks associated with PCOS. Lowering insulin levels also helps to reduce the production of testosterone, diminishing many of the symptoms associated with excess testosterone: body hair growth, hair loss, acne, obesity and cardiovascular risk.

* Metformin (sold as Glucophage) is a diabetes drug that improves both glucose tolerance and insulin sensitivity. About one-third of patients on Glucophage experience gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal bloating, flatulence and loss of appetite), but these are usually temporary and disappear after 1 to 4 weeks.
* Pioglitazone (ACTOS) was developed for use in type II diabetes and works primarily by improving insulin sensitivity and glucose tolerance. There were few notable side effects in clinical trials. Another added benefit seen with Pioglitazone is the reduction of triglyceride levels.
* Rosiglitazone (Avandia) also works by improving insulin sensitivity. A low incidence of side effects was noted in clinical trials.

There are several excellent online resources for people who want to learn more about PCOS. The Polycystic Ovarian Syndrome Association web site has information for patients (some which we have brielfy summarized here), as well extensive listings of ongoing clinical trials and research studies, and support groups all over the US.

This article includes information from the Polycystic Ovarian Syndrome Association.

For more information on this topic, see the HealthLink article Polycystic Ovary Syndrome and Facial Hair.
SOURCE:- © 2003 Medical College of Wisconsin

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