Polycystic Ovaries Women with PCOS usually present with enlarged ovaries with numerous enlarged peripheral cystic follicles and increased central stroma (the middle section of the ovary which produces androgens). Many studies suggest that the polycystic appearance is due to increased production of androgens, which leads to lack of ovulation resulting in the follicle atresia (arrest of development).
The most common symptom of polycystic ovarian syndrome is infrequent or absent menses. Some women have oligomenorrhea, which is defined as less than 8 menses in one year. Other women may go for months without ovulating and require the use of medication to induce their menses. Long-standing absence of menses may increase the risk of cancer of the lining of the uterus by three folds.
Anovulation (Lack of Ovulation)
Women do not ovulate regularly may have a hormonal imbalance between estrogen and progesterone which can lead to irregular, heavy bleeding or no bleeding at all. Remember, that having menses every month does not necessarily mean that ovulation is occurring regularly. Ovulation should be evaluated using ultrasound follicular scans or day 21 progesterone measurements.
Heavy bleeding can be also associated with a variety of gynecological changes such as ovarian cysts, uterine polyps, and uterine fibroids. Typically a sonohysterogram, where saline is injected into the uterine cavity during a pelvic ultrasound or a hysteroscopy (placing a telescope like probe in the uterus), can rule out most causes of bleeding.
Infertility and PCOS
Many women with PCOS are infertile because they do not ovulate regularly due to the hormonal imbalances resulting from insulin resistance. Current treatments include the combination of medications that induce ovulation (Clomid, Letrozole, FSH) and those that decrease insulin resistance (Metformin, Glucophage).
PCOS and Insulin Resistance
There is sufficient research linking PCOS and insulin resistance. This is further verified by the resumption of ovulation that occurs when insulin-sensitizing fertility drugs like metformin are administered. In women with PCOS, the body’s cells do not respond properly to a given amount of insulin so the body compensates by increasing insulin production. Insulin resistance is diagnosed if the glucose to insulin ratio is greater than 4.5 , if the 2 hour glucose tolerance test is greater than 140, or if fasting insulin is greater than 10. We also check the two hour insulin levels and if the insulin levels increase at the two hour level, it is indicative of insulin resistance. Insulin resistance eventually can lead to diabetes mellitus when pancreatic insulin secretion cannot keep up with the glucose consumed by the diet.
The risk of diabetes can be reduced through careful life style modification with an appropriate diet and an exercise program. With our PCOS nutrition and wellness program, many patients have found success with weight management as well as glucose and insulin reduction. Our PCOS nutrition program is headed by a certified nutritionist who will design a specific program tailored to each patient’s goals.
Metformin (Glucophage) sensitizes the cells in the body to glucose and has been shown to decrease testosterone, improve ovulation and pregnancy rate. Women will typically lose weight after initiating metformin and about 20% may experience nausea or diarrhea. The symptoms will lessen with time and improve when Glucophage is taken with meals. Glucophage cannot be taken in women with liver or kidney disease.
Thinning Hair and PCOS
Acne and PCOS
All patients with hirsutism undergo a physical and laboratory examination, which includes menstrual history, evaluation of progression of hair growth, review of current medications, etc. The laboratory evaluation should include thyroid hormones, prolactin levels, fasting insulin, glucose levels, free testosterone, DHEAS and 17-hydroxprogesterone. These laboratory fertility tests are typically performed in the morning before day eight (8) of the menstrual cycle.
Hirsutism is present in approximately 25% of women and in a higher percentage of those who are infertile. Hirsuitism may signal underlying endocrine, or metabolic, abnormalities such as androgen excess and PCOS. Other signs of elevated androgens include hair loss, irregular menses, acne, Acanthosis Nigerians infection, and others. Approximately 5-15 % of women with hirsutism have no identifiable underlying cause. Once diagnosed with hirsutism, patients are placed on individualized treatment plans that may include oral contraceptives and Aldactone.