Polycystic Ovary Syndrome (PCOS)

Around one in five women of reproductive age have small cysts on their ovaries. While polycystic ovaries are present in women of all ages, many show no symptoms of PCOS. Ovaries do not suddenly become polycystic; but women who have always had polycystic ovaries may develop symptoms at any time. If a women experiences symptoms from polycystic ovaries the condition is then known as polycystic ovary syndrome and may require specialist treatment.

Polycystic ovaries contain many small cysts—at least ten. Some of these cysts contain eggs, some are dormant, and others might secrete hormones. The cysts are quite small, usually no bigger than 8mm. Blood tests might also reveal changes in hormone levels which are characteristic of polycystic ovaries, but these levels vary considerably from one woman to another.

Polycystic ovaries may be hereditary and the cause is believed to involve an inability of the ovaries to produce hormones in the correct proportions. Women who have PCOS may find they do not get pregnant as quickly as they would plan. However, if pregnancy does not occur within a reasonable period of time effective treatment is available.

The symptoms of PCOS

1. Irregular periods

The imbalance of hormone production from the ovaries may result in either irregular, heavier or more prolonged menstruation, or in some women not occur at all.

2. Fertility

Irregular ovulation usually means that pregnancy is more difficult to achieve. If ovulation is not taking place, it is not possible to conceive without treatment.

3. Miscarriage

The polycystic ovary syndrome is now recognised to be one of the conditions which increase the risk of miscarriage. This is due to the higher blood levels of the hormone LH often found in women with PCOS.

4. Skin problems

One of the hormones which may be increased in unusually high amounts from the ovary is testosterone, the ‘male’ sex hormone which circulates in both men and women. Excessive testosterone levels in women may be the cause of acne and unwanted hair on the face, chest, arms and legs. The levels of testosterone in women with PCOS are still much lower than those found in men.

5. Body weight

Weight gain is common in women with PCOS, however not all women with PCOS are overweight. Some women with polycystic ovaries only develop symptoms of the syndrome when they put on weight.

Long Term Health and the Polycystic Ovary Syndrome

There is no proven link between the cysts of polycystic ovaries and ovarian cancer. However, although the risk is still very rare, women with few or absent periods are at an increased risk of endometrial cancer. This can happen when the internal lining layer of the womb (the endometrium) becomes too thick. Regular shedding of the endometrium by having regular periods, prevents endometrial cancer. If the endometrium appears thick on an ultrasound scan or if very irregular, prolonged bleeding occurs then curettage might be advised.

Treatment for Women with the Polycystic Ovary Syndrome

The polycystic ovary syndrome should not be regarded as a disease as it is a physical characteristic of some women which cannot be permanently changed. However, the symptoms described above may be controlled with medical treatment. All women with polycystic ovaries should try to remain a normal weight.

1. Irregular periods

For women who have no wish to become pregnant, menstrual periods may be controlled by a low dose oral contraceptive pill. Women who cannot take the pill should try a progestogen-only treatment (for example Provera or Primolut N) for 12 days each month. Any irregular bleeding should be checked by a doctor who may advise an ultrasound scan or curettage. A pap smear should be taken at least once every two years.

2. Difficulty in conceiving

This is most likely due to lack of regular ovulation in women with polycystic ovaries. However other causes of infertility may also be present. When ovulation is irregular or not occurring at all, drug or hormone treatment may be required. The most common treatment is clomiphene (Clomid) which is taken as a tablet for five days early in the cycle.

Clomiphene can cause thickening of mucus in the cervix and this may prevent the passage of sperm throughout the cervix. Therefore, although clomiphene may cause ovulation, pregnancy will not always occur. Clomiphene is not always useful in women with polycystic ovary syndrome because it may exaggerate the rise in blood levels of LH during the first part of the cycle. This reduces the chance of a successful pregnancy.

If clomiphene does not help, hormones which are injected may be useful. The hormone follicle stimulating hormone (FSH) is a pituitary hormone which is synthesised in the laboratory. FSH is mainly responsible for stimulating the growth of cysts or follicles. Polycystic ovaries are usually very sensitive to hormonal stimulation and commonly more than one follicle will grow when the injections are given. Because of this, courses of treatment begin with low doses and the response is carefully monitored by blood tests and ultrasound scans. If monitoring shows that too many follicles are developing and the risk of multiple pregnancy is high, the treatment will be stopped and it may be necessary to use contraceptive measures for several days.

When other treatments have not been successful in causing a pregnancy, invitro fertilisation (IVF) may be offered to women with the PCOS. Women with polycystic ovaries given gonadotropins (FSH) are at an increased risk of a serious, uncommon condition called the ovarian hyperstimulation syndrome (OHSS). Although OHSS is still highly unlikely, a woman with PCOS having IVF must be carefully monitored. For further information on OHSS please see the Treatment of Infertility> Oestrogen, OHSS and IVF section of this website.

3. Skin problems

Acne and unwanted body hair may be reduced by taking a combination of tablets. Oestrogen (as found in the oral contraceptive pill) is combined with an antiandrogen tablet (usually spironolactone or cryproterone acetate) and the combination must be taken for many months to obtain some benefit. This therapy is of course contraceptive and therefore is of no use when trying to conceive. Waxing and electrolysis may be used to remove unwanted hair while waiting for the hormone treatment to work. However, they should be performed by a trained therapist as scarring can result from unskilled treatment. If the skin problem is related to the polycystic ovary syndrome, hormonal treatment is the logical solution.