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Polycystic ovary syndrome (PCOS), also known as polycystic ovarian syndrome, is a common endocrine condition that affects how a woman’s ovaries work. Described as a low-grade chronic inflammatory state, due to decreased progesterone and elevated estrogen levels, it is responsible for approximately 85% of cases of irregular periods in women.
The exact prevalence is unknown due to a lack of awareness amongst the community, however it is estimated to affect between 5 to 15% of women. A higher prevalence of PCOS is common in population studies where higher incidence of obesity and diabetes exist.
The 3 main features of PCOS are:
|Irregular periods||This means the ovaries are not regularly releasing eggs|
|Excess androgen||Male dominant hormones which may cause excess acne, facial or body hair and male pattern baldness (serum total testosterone > 2 nmol/L)|
|Polycystic ovaries||An increased number of antral follicles causing enlarged ovaries (specifically 12 or more antral follicles 2 to 9μm in diameter or ovarian volume > 10mL)|
If you have at least 2 of these features, your Doctor may diagnose you with PCOS in absence of other possible causes. Such as an adrenal disorder, hyperthyroidism, prolactinoma and in rare cases, androgen secreting tumours.
Accordingly there are 4 unique types of PCOS:
- Type A (irregular periods, excess androgen, polycystic ovaries)
- Type B (irregular periods, excess androgen, normal ovaries)
- Type C (regular periods, excess androgen, polycystic ovaries)
- Type D (irregular periods, normal androgen, polycystic ovaries)
The effect of PCOS on a woman’s fertility varies greatly depending on the phenotype.
In fact non-obese women with polycystic ovaries but no symptoms (irregular cycles, acne, facial or body hair) have a similar ‘time to pregnancy’ compared to women without polycystic ovaries.
On the other hand women with elevated androgen levels are at higher risk of having children with neuropsychiatric disorders, particularly attention deficit hyperactivity disorder, autism spectrum disorder, Tourette’s disorder and chronic tic disorder.
Source: Cesta A E, et al. (2019)
Although hyperandrogenism and menstrual dysfunction is common in women with PCOS they are not associated. Studies show that the severity of menstrual dysfunction, in women with PCOS, is closely linked to the degree of insulin resistance (dynamic state) rather than androgen levels. This suggests decreasing (elevated) insulin will have the biggest effect on menstrual cycles.
Despite the name polycystic ovarian syndrome, your ovaries do not have any cysts.
To understand PCOS, we need to go back to the very beginning. Approximately 3 months prior to ovulation, tiny sacs each containing an egg, known as follicles begin to grow. This growth and release is predominantly regulated by the female hormones estrogen and progesterone. However women with elevated levels of testosterone during this early stage of growth experience two to three times the normal number of follicle arrest. This is what gives the appearance of small cysts in the ovaries under ultrasound and hence the name polycystic ovaries.
Interestingly normal puberty in girls cause many of the features of PCOS, such as irregular periods, elevated androgen levels, increased luteinizing hormone (LH), insulin resistance and polycystic ovaries. This is one of the reasons why a Doctor might not send a young woman for ultrasound diagnosis, particularly if it has been less than 8 years since the woman began menstruating.
Source: Legro R S, et al. (2013)
However the sooner anti-androgenic treatment is started in women with PCOS, the higher the probability of childbirth following spontaneous ovulation and conception.
In fact women who start treatment during adolescence see a mean reduction in time to first childbirth of 0.6 years (5.40 vs 6.00), and even greater in women with only mild hyperandrogenemia.
Source: Elenis E, et al. (2021)
In short, women with PCOS normally have problems with fertility because ovulation occurs intermittently or stops entirely and endometrial receptivity is altered. In addition, women with PCOS commonly exhibit high levels of insulin, with 65-80% being resistant to insulin, causing difficulty for women trying to lose weight.
However as women get older (> 30), the prevalence of polycystic ovaries tends to decrease, along with androgen levels, causing the return of normal menstrual cycles in some women. However embryo quality also decreases with age such that immediate treatment is normally recommended over a wait and see approach.
Symptoms of Polycystic Ovary Syndrome
Polycystic ovary syndrome does not usually produce symptoms until part way through puberty when the ovaries begin to produce hormones in significant amounts.
These symptoms can include:
- periods that are infrequent, irregular or absent
- difficulty getting pregnant (due to irregular or absent ovulation)
- male pattern hair growth
- darkened, thickened armpit skin (acanthosis nigricans)
- thinning hair and hair loss
- oily skin or acne
- weight gain or obesity
Risks Associated with Polycystic Ovary Syndrome
Women diagnosed with Polycystic Ovary Syndrome are also at higher risk of other complications which can complicate the trying to conceive journey.
These risks include:
- Endocrine disorders
- Cardiovascular disease
- Gestational diabetes, Impaired glucose tolerance, Type 2 diabetes
- Liver disease
- Endometrial cancer
- Pregnancy complications
- Inflammatory disorders
- Cognitive impairment
- Mental disorders
- Obstructive sleep apnea
Causes of Polycystic Ovary Syndrome
The exact cause of PCOS is currently unknown, however researchers are slowly piecing together the puzzle which may involve elevated androgen levels in utero, high sucrose diets consumed prepuberty and or gene mutations.
Diagnosis of Polycystic Ovary Syndrome
Please see a Doctor if you have any typical symptoms of PCOS. The Doctor will ask about your symptoms and history, take your blood pressure and carry out a physical examination.
Treatment of Polycystic Ovary Syndrome
Currently there is no official cure for PCOS, however many of the symptoms and underlying effects of PCOS can be improved and sometimes normalised.
Understanding your unique type of PCOS is paramount to effective management long term, alongside a peer support group to lean on for good mental health.
Source: Ranasinghe B A, et al. (2021)
Although women with PCOS are traditionally diagnosed as type A, B, C or D, recent genetic analysis categorised PCOS into 3 unique subtypes:
Each subtype involves different biological pathways and environmental factors. This explains why no individual treatment option has proven to be 100% effective across all women with PCOS.
Source: Dapas M and Dunaif A, (2022)
Fortunately, after personalised treatment, most women with PCOS are able to become pregnant.
In fact, current treatments for PCOS range from lifestyle, environmental and dietary changes to medication or surgery. Among these treatment options, some have long term benefits while others are only temporary and better suited to women with PCOS trying to conceive.
Women diagnosed with polycystic ovary syndrome are also at higher risk of other disorders and complications. These risks include…. Read more
The exact cause of PCOS is currently unknown, however researchers are slowly piecing together the puzzle which may involve elevated…. Read more