Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a long-term condition in women in which there is an abnormality in female sex hormones. This is associated with a range of health problems including increased facial and body hair growth, increased tendency to develop type 2 diabetes, irregular menstrual cycles and reduced fertility.

PCOS is common, affecting between 12-21% of women of reproductive age. It is estimated that around 70% of women with PCOS do not know they have the condition.

Signs and symptoms

Women are often diagnosed with PCOS in late adolescence or in their 20s. The symptoms vary, but they can include:

• Facial and body hair growth;
• Irregular menstrual cycles (infrequent or too frequent), or no menstrual cycles at all;
• Problems with fertility and getting pregnant;
• Weight gain (most women with PCOS are overweight or obese);
• Thinning or loss of hair on the scalp;
• Acne;
• Acanthosis nigricans, which is dark patches of skin that tend to form on the neck and breasts and in the armpits and groin, and;
• Body shape changes, including reduced size of breasts and, very rarely, an enlarged clitoris.

Women with PCOS can also be at greater risk of experiencing mental health problems such as:

• Problems with body image and low self-esteem;
• Anxiety;
• Depression;
• Eating disorders, and;
• Problems with sex.

PCOS is also associated with:

• Type 2 diabetes or a tendency to develop it;
• High blood cholesterol, and;
• High blood pressure (hypertension).

Causes

The exact cause of PCOS is unclear. However, it involves abnormalities in a number of hormones, including:

• Luteinising hormone, produced by the pituitary gland;
• Male sex hormones (androgens), produced by the ovaries, adrenal glands and fat and skin cells;
• Female hormones called progesterone and oestrogen, produced by the ovaries, and;
• Insulin, a hormone produced by the pancreas. In PCOS, the body becomes resistant to insulin, which predisposes to type 2 diabetes.

These hormonal changes can prevent the ovaries from releasing fully mature eggs. Usually, once each menstrual cycle during ovulation, one or more eggs are released from the ovaries into the fallopian tubes. The eggs then pass to the uterus, where, if they are fertilised, can develop into an embryo.

In PCOS, eggs are not released, but instead form tiny cyst-like structures in the ovaries. Over time, these cysts can build up and the ovaries can become 'polycystic'. Because eggs are less likely to be released from the ovaries, women with PCOS are more likely to have problems with fertility.

The female reproductive organs showing a polycystic ovary. 

Androgens are known as 'male' hormones, although small amounts are naturally produced in the female body. When levels of androgens are raised in women, this can lead to the development of features more common in males. This results in some of the symptoms experienced in PCOS, such as increased body hair, loss of hair on the scalp and acne.

Most women with PCOS have insulin resistance whether they are overweight or not. Metabolic syndrome is also increased in women with PCOS. Metabolic syndrome is a term given to the consequences of insulin resistance, which is a range of health problems including type 2 diabetes, high blood pressure (hypertension) and high blood cholesterol.

Insulin works by helping glucose (sugar) pass from the bloodstream into cells in the body. In PCOS, this process can be affected. This occurs because although the pancreas can still make insulin, the cells no longer respond the way they should (called insulin resistance). When glucose can no longer enter the cells and instead stays in the bloodstream, it can result in the pancreas making more insulin to try to control blood glucose levels. Eventually, type 2 diabetes can develop, in which the pancreas can no longer produce enough insulin to control glucose levels.

Methods for diagnosis

There is no one test to diagnose PCOS. So to help make the diagnosis of PCOS, your doctor will usually assess for two out of the following three criteria:

• Infrequency or absence of periods;
• Symptoms or blood test results demonstrating increased androgen levels, and;
• Evidence of polycystic ovaries using an ultrasound.

A transvaginal pelvic ultrasound is generally only performed on women over 18 years of age. It is important to recognise that not every woman who has polycystic ovaries on ultrasound will have PCOS.

When diagnosing PCOS, your doctor will need to make sure that other health conditions are not causing your symptoms. They may also want to do tests to investigate how PCOS is affecting your general health.

Tests can include:

• Blood pressure test;
• Assessment of your weight;
• Oral glucose tolerance test to assess for insulin resistance, and;
• Blood cholesterol levels.

Types of treatment

If you have PCOS, there are a range of treatments available. You may need to work with a range of healthcare professionals such as an endocrinologist, fertility specialist, dietitian and exercise physiologist to manage the condition.

Lifestyle

Managing your lifestyle is a very important part of controlling PCOS and reducing the risk of health problems that can arise.

Weight loss

If you are overweight or obese, aiming at achieving a healthy weight can help to improve PCOS symptoms, improve blood glucose control and help with other health conditions such as high blood pressure (hypertension). Weight loss can be challenging, but even losing a small amount, for example 5% of your body weight, can help.

Healthy diet

A healthy, well-balanced diet can help to manage PCOS symptoms. A low-fat diet with plenty of fruits, vegetables and whole grains is recommended. If you need help planning your meals, a dietitian can provide guidance.

Physical activity

Regular physical activity can help to manage PCOS. However, particularly if you have type 2 diabetes as well as PCOS, it's important to talk to your doctor about what activities are suitable and any precautions you may need to take in order to be active safely.

Physical activity can help to manage symptoms associated with polycystic ovary syndrome. 

Quitting smoking

Smoking can make the health problems that occur with PCOS significantly worse. If you smoke, your doctor can advise you on treatments and approaches that can make quitting smoking easier.

Treatments for menstrual problems

The lifestyle measures described above can help make your menstrual cycle more regular. Medications can also be prescribed. Your doctor will advise you on what medications are most suitable for your situation.

These include:

• The combined oral contraceptive pill;
• Cyclic progesterones, and;
• Metformin, a drug for type 2 diabetes that can help to stimulate ovulation and the regularity of the menstrual cycle.

Fertility treatments

The lifestyle measures described above can help improve fertility. Medications that help to stimulate follicle development and ovulation include clomiphene citrate, metformin and gonadotrophins.

In vitro fertilisation (IVF) may help to achieve pregnancy if other fertility treatments are not successful.

Surgery

Laparoscopic surgery can be used to either remove an ovary or treat it. It can help to remove tissue that is producing androgens (male hormones) and improve the hormone imbalances in PCOS.

In laparoscopic ovarian drilling (LOD) a laparoscope is inserted into the pelvis and used to destroy tissue in the ovaries. This is done either with heat or a laser. The effect of these procedures is not permanent.

Prevention of long-term health complications

The lifestyle measures described above can help reduce insulin resistance and improve your blood pressure and blood glucose levels. This can reduce the risk of serious health problems such as type 2 diabetes and heart disease.

Metformin may also be prescribed to help reduce insulin resistance.

Mental health

Dealing with some of the symptoms caused by PCOS can be challenging. Women with PCOS can be at greater risk of a range of mental health problems, including depression, anxiety and eating disorders. Seeking support or advice from your doctor or a mental health practitioner can help.

Treatments for hair growth

There are a range of options available to reduce body hair. Cosmetic hair-removal treatments, particularly laser hair removal, are recommended.

Eflornithine hydrochloride is available in a cream. It disrupts an enzyme in hair follicles that is necessary for the hair to grow. It can help to prevent or delay facial hair regrowth and may improve the effect of cosmetic hair-removal treatments.

If these treatments are ineffective, or not an option, some medications may help.

These include:

• The combined oral contraceptive pill, and;
• Anti-androgen medications (aldactone or cyproterone acetate).

Your doctor can advise on what therapies may be suitable for you.

Non-medication options can also be used to control hair growth, such as plucking, waxing and laser hair removal.

Acne

The combined oral contraceptive pill can help to improve acne. Topical and oral medications can also be prescribed to treat acne specifically.

Your doctor can advise you on suitable therapies. 

Potential complications

Because of the hormone imbalances that occur in PCOS, it can increase your risk of a range of serious health problems, including type 2 diabetes, high blood pressure (hypertension), heart attack and stroke.

When you have PCOS, you may need to see your doctor more regularly to check for these conditions.

Cancer

Women with PCOS can have an increased risk of endometrial cancer.

Prognosis

PCOS is a long-term condition that may need to be managed for the rest of your life. With healthy lifestyle measures and appropriate treatment, most women with PCOS can achieve pregnancy and limit the symptoms and health problems the condition can cause.

In some women, PCOS may resolve without treatment around the age of 30-40 years.

Prevention

PCOS cannot always be prevented, but lifestyle measures such as eating a healthy diet, exercising regularly and keeping your weight within a healthy range can reduce your risk of developing the condition, as well as helping to prevent or reduce many of its associated health problems.