Polycystic Ovarian Syndrome (PCOS)
The terms PCO or PCOS are often confusing. Polycystic ovaries (PCO) refer to the appearance of the ovary as seen by imaging techniques such as ultrasound. In a normal ovary, one or two small developing follicles are seen whereas in a polycystic ovary many, many follicles are present.
Polycystic Ovary Syndrome (PCOS) means a combination of 2 or more findings:
- irregular periods;
- increased hair growth or acne or raised levels of male hormones (androgens);
- appearance of many follicles as seen by ultrasound.
PCOS is rarely found in Asian women, but occurs in around 5-8% of Caucasian women (and probably Maori and Polynesian women), and even more frequently in women from India and the Middle East.
Symptoms vary with severity of the syndrome, ethnicity and lifestyle. Persistent acne, increased body hair in areas such as upper lip and chin, abdomen and bikini line, and oligomenorrhea (periods more than 35 days apart) are symptoms which result from increased androgen production by the polyfollicular ovary.
- Don’t ignore irregular periods as they may increase the risk of cancer of the womb;
- Don’t smoke;
- If at all possible, maintain your weight in the lower BMI range for your ethnicity (e.g. 20-22 for Caucasians, 18.5-21 for Asians/Indians);
- Exercise very diligently to help reduce insulin levels and avoid long term complications;
- Anti-androgens can significantly improve recurrent acne and/or male type hair patterns if taken for the medium term (e.g. for 6 months or more);
- If you are not pregnant after 3 to 6 months of trying, seek expert medical help, especially if you are lean and/or have irregular periods;
- If circumstances allow, consider trying for pregnancy by around 30 years age so that age-related factors are not an additional issue.
There are two physical appearances (phenotypes) of PCOS women – lean and overweight. Lean women with PCOS will have symptoms from puberty. Heavier women with PCOS may be relatively asymptomatic in their teens while maintaining a fit and lean physique and only develop menstrual irregularity when a more sedentary lifestyle after school leads to weight gain and less overall exercise and activity. Immigrant women often present with this history.
PCOS can be associated with longer term risks, including diabetes, raised blood pressure, abnormal cholesterol, sub fertility and cancer of the womb. Mostly these can be avoided or delayed by a healthy lifestyle, such as no smoking, maintaining a strong exercise ethic, avoiding weight gain, and checking health with your general practitioner on a regular basis. Women with a family history of diabetes need to be extra cautious.
We don’t really know what causes PCOS and it seems unlikely to be just one factor. Genes do matter – brothers and sisters of women with PCOS often have similar changes in their blood tests. Weight gain exacerbates abnormal androgen levels and symptoms.
The condition of PCOS is managed rather than cured. Early diagnosis is encouraged. Women with PCOS are advised to maintain significant levels of exercise and a slim body mass index (BMI) (ideal BMI 20-22) so that the risks of diabetes and subfertility are minimised.
A diagnosis of PCOS should be sought in women with persistent acne and allows judicious use of anti-androgen therapy. Anti-androgen therapy should not be used when conception is required but can provide significant relief from excessive hair growth and recurrent acne. Anti-androgens are best used in combination with physical methods of hair removal.
PCOS women with abdominal weight gain will often recommence regular ovulatory menses with more exercise and weight loss.
It is important to recognise appropriate waist measurements and BMI for different ethnicities. For example, Asian and Indian women often have metabolic changes and irregular cycles due to PCOS at a BMI which would not lead to the same changes in a person of European descent.
Very lean PCOS women may need assistance to ovulate and there are several interventions which are useful (clomiphene, metformin, and ovarian diathermy). Usually a fertility specialist would assist the general practitioner in this situation, and more complex assisted technology is only occasionally required. PCOS women should be aware, however, that they may be more at risk of pregnancy related-complications especially gestational diabetes.
Infertility is often feared as a consequence of PCOS but is often not an issue. Women with PCOS should use contraception when not desiring pregnancy.