Ovulatory Disorders (PCOS)

What is polycystic ovarian syndrome?

There are many types of ovulatory disorders that contribute to fertility challenges. Polycystic ovarian syndrome (also known as PCOS) is one of the most common endocrine disorders I see in my practice.

Polycystic ovarian syndrome is a chronic condition and a common cause of infertility. It is characterised by abnormal growth and release of eggs from the ovaries. A hormonal imbalance results in enlarged ovaries containing several small cysts (fluid-filled sacs). It is most common in child bearing age and is rare after menopause.

What causes PCOS?

Like many other ovulatory disorders, the exact cause of polycystic ovarian syndrome is unknown. However, several factors including genetics have been implicated. Those with a family history of polycystic ovarian syndrome are at a higher risk of developing this condition.

Researchers have also found an association between excessive insulin production and the development of polycystic ovarian syndrome. The insulin hormone regulates blood sugar levels and any disorder affecting the insulin mechanism may result in excessive insulin secretion, which triggers androgen secretion from the ovaries.

Low grade inflammation, in response to ingestion of certain foods, may lead to the release of substances that can cause insulin resistance and cholesterol accumulation in the blood vessels, or atherosclerosis. Clinical studies have demonstrated the presence of low grade inflammation in those with polycystic ovarian syndrome.

What are the symptoms of PCOS?

Symptoms of ovulatory disorders, including polycystic ovarian syndrome, can vary from person to person depending on the nature and severity of the condition. Some of the symptoms include infertility, absent or irregular menstrual cycle and obesity or an accumulation of fat, usually around the waist.

Abnormal facial and body hair, adult acne and baldness or hair thinning may also develop due to excessive androgen secretion. In some patients black or dark brown patches are seen around the skin of the neck, arm, breasts or thighs. 

Patients often experience anxiety, depression and sleep apnoea (a common cause of snoring and poor sleep).

How is PCOS diagnosed?

The diagnosis of ovulatory disorders is complex. Diagnosis of polycystic ovarian syndrome is based on the medical history along with a physical and pelvic examination to evaluate the condition of the patient and help identify the underlying cause. Blood tests can help to determine the level of various hormones. 

Additional tests such as a glucose tolerance test and evaluation of blood cholesterol may also be useful. Pelvic ultrasound is performed to evaluate the appearance of the ovaries and the uterine lining.

How is PCOS treated?

The treatment of polycystic ovarian syndrome is based on the symptoms and individual concerns such as infertility, irregular menstrual cycle, acne or obesity. 

Lifestyle changes are the first line treatment. Most people with polycystic ovarian syndrome are overweight and obese, so weight loss is a key part of the overall plan.

Infertility may be treated with ovulation-inducing drugs. Clomiphene citrate, an oral anti-oestrogen, may be prescribed to patients. In some cases, metformin can be added to clomiphene to help induce ovulation. In patients not responding to clomiphene and metformin, gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) can be administered by injection.

Surgery may be recommended in patients who do not respond to medications. Laparoscopic ovarian drilling, an outpatient surgical procedure, may be used to treat the condition and induce ovulation.

IVF is also an option should the above medications not be effective or appropriate.

As with many ovulatory disorders, oral contraceptives may be prescribed for the management of irregular menstrual cycles. Oral contraceptives effectively reduce the level of androgens and are also successful in reducing excessive body hair growth while minimising the risks of uterine cancer.

Lifestyle modifications and anti-diabetic medications may be prescribed for the management or prevention of obesity and diabetes.

What are the risks associated with having PCOS?

Patients with polycystic ovarian syndrome are at increased risk of developing other medical conditions such as diabetes, high cholesterol, cardiovascular disease, pregnancy-induced high blood pressure, gestational diabetes, miscarriage or premature delivery. These patients are also at risk of uterine cancer, anxiety, depression and disordered sleep.