What is Polycystic Ovarian Disease?
Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder in women of childbearing age worldwide. It was first described by Stein and Leventhal in 1935, and it affects between 5% to 15% of women, depending on the criteria used to diagnose it. PCOS is usually defined by at least two of these three conditions: irregular periods, high levels of male hormones (either seen through physical signs or confirmed with a blood test), and cysts in the ovaries. It’s important, however, to rule out other conditions that could cause similar symptoms, like thyroid disease, high levels of the hormone prolactin, or non-typical adrenal hyperplasia, a group of inherited conditions that affect your adrenal glands. In some cases, more tests may be needed if other causes are suspected.
Unfortunately, despite its commonness, PCOS often goes undiagnosed. It can take multiple doctor visits or even different doctors to correctly identify PCOS, often spanning over a year. This can be frustrating for patients. Delays in diagnosis can allow related health problems to become worse, making it harder to make lifestyle changes that could improve PCOS symptoms and overall quality of life.
Several health issues are linked to PCOS including infertility, metabolic syndrome (a condition involving high blood pressure, high blood sugar, abnormal cholesterol levels, and body fat around the waist), obesity, impaired glucose tolerance (prediabetes), type 2 diabetes, increased heart disease risk, depression, sleep apnea, endometrial cancer (cancer of the lining of the uterus), and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (fat accumulation and inflammation of the liver). With each of these conditions, it’s important to screen for them and for doctors to be on the lookout for any symptoms appearing in people with PCOS.
What Causes Polycystic Ovarian Disease?
PCOS, or Polycystic Ovary Syndrome, is a complex health condition influenced by many factors. It has been found that some genes play a big part in the development of this condition by impacting the production and function of hormones, such as steroids and male hormones (androgens). Studies on twins suggest that inheritance plays a significant role, with about 70% of the risk related to genes.
However, the environment also plays an essential role in the development and severity of PCOS. What this means is that even if someone has the genes that make them vulnerable to PCOS, the condition may not develop unless certain environmental factors trigger it. These triggers can include being overweight and having insulin resistance, a condition where the body doesn’t respond well to the hormone insulin. There are also theories that exposure to male hormones before birth could be a factor.
Overall, there’s a combination of genetic and environmental factors that influence whether a person develops PCOS. This helps explain why the condition can vary so much from person to person.
Risk Factors and Frequency for Polycystic Ovarian Disease
Polycystic Ovary Syndrome (PCOS), an issue with the hormones, is the most common health problem for women who are of childbearing age all around the world. It can affect between 5 to 15% of women depending on which criteria are used for diagnosis.
- The broader Rotterdam criteria estimate a higher prevalence than the criteria established in 1990 by the National Institute of Health (NIH).
- According to a 2012 report by the NIH, PCOS likely affects about 5 million women of childbearing age in the US alone.
- Each year, around $4 billion is spent on diagnosing and treating PCOS. This doesn’t even include other serious health problems that often come with PCOS.
- Many conditions have been linked to PCOS, such as infertility, metabolic syndrome, obesity, impaired glucose tolerance, type 2 diabetes, increased risk of heart disease, depression, sleep apnoea, endometrial cancer, and liver disease (NAFLD/NASH).
- PCOS is more common in certain groups, including women with close relatives with PCOS, women who were overweight before puberty, women with congenital virilizing disorders, women with unusual birth weights (either high or low) for their age of gestation, women who had premature adrenarche (early onset of puberty), and women who use a particular type of epilepsy drug (valproic acid).
- Research also shows that Mexican American women might experience PCOS more often than non-Hispanic white and African American women.
Signs and Symptoms of Polycystic Ovarian Disease
For diagnosing Polycystic Ovary Syndrome (PCOS), a full medical history and physical examination are crucial. Out of the three main things doctors look for in diagnosing PCOS, two of them – menstrual history and signs of high male hormones (hyperandrogenism) – come directly from the patient’s history and physical exam. It’s also important to rule out other conditions that could cause the same symptoms as PCOS. So, doctors need to know about any other health problems that may be affecting a patient.
Testing for Polycystic Ovarian Disease
To diagnose Polycystic Ovary Syndrome (PCOS), a woman should meet at least two out of three criteria: chronic lack of ovulation, an excess of male hormones either visibly or through testing, and the presence of cysts on the ovaries, as seen by an ultrasound. These are all aside from any other health issues. When diagnosing, it’s important to rule out diseases with similar symptoms too, like thyroid disease and non-classic congenital adrenal hyperplasia with 21-hydroxyprogesterone deficiency.
Diagnosing PCOS in teenagers is tougher. Many symptoms of PCOS, like acne, irregular periods, and increased insulin levels, are also common in puberty. Therefore, irregular periods for the first 2 to 3 years after a girl begins menstruating can be normal due to an underdeveloped hormonal system. Persistent irregular period beyond this phase might indicate a greater chance of hormonal problems. Ultrasound might not be very helpful in teenagers because they tend to have larger ovaries with multiple cysts.
Having a menstrual cycle longer than 35 days might be a sign of chronic lack of ovulation, and this can lead to problems like inability to conceive, abnormal growth of the uterus lining, and even uterine cancer.
Hyperandrogenism, or an excess of male hormones, can be diagnosed by checking for hair growth patterns, hair loss, or acne. These signs can be used instead of hormone testing for women. In teenagers, only unusual body hair growth (hirsutism) is used as a substitute for hormone testing. However, if there are signs of masculinization, such as increased muscle mass or deepening of the voice, a doctor may consider looking for an androgen-producing tumor in the ovaries or adrenal gland.
Assessing the size and shape of ovaries through ultrasound can help in diagnosing PCOS. With more advanced equipment, at least 25 small follicles (tiny sacs where eggs develop) in the ovary can suggest a diagnosis of PCOS.
Women with PCOS are also at higher risk for heart disease, metabolic disorders, and other health problems. They should be tested for these and treated if necessary. These conditions include:
* Infertility: Women wanting to become pregnant may be checked for ovulation, even if they have regular periods.
* Endometrial Cancer: Women with PCOS face a higher risk of endometrial cancer. Women should report any irregular or unexpected bleeding, although routine monitoring is not recommended.
* Obesity and metabolic disorder: Women with PCOS should have their Body Mass Index (BMI) and waistline measured as obesity increases the risk of having an excess of male hormones and metabolic disorders.
Additionally, an oral glucose tolerance test (a kind of blood sugar test), can be a good way to screen for impaired glucose tolerance and type-2 diabetes, which are more common in women with PCOS.
Finally, women with PCOS have a higher likelihood of developing non-alcoholic fatty liver disease and depression, so they should be screened and treated for these as required.
Treatment Options for Polycystic Ovarian Disease
For overweight women and adolescents with PCOS (polycystic ovary syndrome), exercise and a calorie-restrained diet are the best initial steps for weight loss and improving insulin resistance (when your body doesn’t respond to insulin as well as it should). Reducing carbohydrate intake in hopes of improving insulin resistance hasn’t shown any significant benefits.
Hormonal contraceptives, which can come as pills, patches, or vaginal rings, are the top choice for managing irregular periods, excessive body/facial hair (hirsutism), and acne. Progestin, an ingredient in hormonal contraceptives, helps reduce the production of certain male hormones linked to these conditions. It’s important to check if there are any reasons why a patient shouldn’t take hormonal contraceptives; for instance, if they’re over 35 and smoke more than 15 cigarettes a day, have uncontrolled high blood pressure, or uncontrolled diabetes with severe circulatory problems.
Metformin, a medication typically used for type 2 diabetes, is a potential choice when lifestyle changes don’t work. Metformin can prevent progression from insulin resistance to diabetes, improve menstrual cycles, and decrease certain heart disease risk markers. It can also be used as a second-choice treatment for menstrual irregularities when hormonal contraceptives aren’t suitable.
Clomiphene citrate is the first choice for PCOS patients struggling with infertility. It’s a drug that interferes with the actions of estrogen in the body and stimulates ovulation. Letrozole, another medication, blocks estrogen production and has been shown to be successful in treating fertility issues related to PCOS. Metformin is sometimes used alongside fertility treatments in PCOS patients.
Hyperandrogenism (the condition where the body produces too many male hormones) needs long-term care and takes time to notice results. While waiting for medications to kick in, temporary hair removal methods can be tried. Oral contraceptives can help lower androgen levels and manage issues like excessive body/facial hair. If hair growth isn’t adequately controlled after 6 months to a year of oral contraceptives, anti-androgen drugs can be added to the treatment.
There are other insulin sensitizing treatments for PCOS patients such as GLP-1 agonists, DPP4 inhibitors, SGLT2 inhibitors, a PPARg agonist, and myoinositol, an over-the-counter supplement which can improve insulin sensitivity. These treatments can be helpful for various individual needs, such as weight loss or fertility treatment. However, more research and data are needed for some of these treatments before they can be widely recommended.
What else can Polycystic Ovarian Disease be?
Doctors have to consider various conditions that can have similar symptoms when diagnosing polycystic ovarian disease. These conditions are:
- Use of male hormone-related steroids
- Underactive thyroid (hypothyroidism)
- Adrenal hyperplasia that comes on later in life
- Excessive hair growth that is considered ‘idiopathic’ (without a known cause) or inherited in the family
- Ovarian cancer
