Fertility Health

The Polycystic-Ovary Syndrome (PCOS)

"Are my ovaries sick?", "Can I ever have children?" - these are common questions following a PCOS diagnosis, which is frightening for many women. But the PCO syndrome is a complex condition with many facets and only a few of these facets are present in each individual case!

What is PCOS?

The Polycystic- Ovary syndrome is the most common hormone disorder in women. PCO here is the abbreviation for polycystic ovaries, a term that refers to a certain appearance of the ovaries: There is a greater number of small follicles compared to normal ovaries. Good to know: The term polycystic ovaries is somewhat confusing, since it is not about cysts on the ovary, but about a certain appearance of the ovaries. It is estimated that about 5 to 10 % of all women are affected by PCO syndrome.

What are the symptoms of PCOS?

Increased male hormone or androgen levels is the most common symptom. Typical symptoms resulting from that can be: acne, greasy skin, increased and unwanted hair growth in the area of the body and accelerated hair loss in the scalp area. Irregular ovulations with the consequence of irregular menstrual cycles and irregular periods are almost always a consequence of this hormonal disorder. Typical in this context is also the often somewhat delayed puberty of women with PCOS. When looking at an ultrasound image, one can then find the many small follicles, which can appear like a string of beads. Sometimes, a PCOS diagnosis can happen in the context of a laparoscopy.

Interesting fact: Tests on animals have shown, that PCO can be triggered artificially by the addition of male hormones.

More possible symptoms of PCOS include weight gain, difficulties getting pregnant, an increased risk of diabetes and high blood sugar, high blood pressure and emotional challenges such as depression or anxiety.

What is causing PCOS?

The exact causes of the syndrome are unclear, but what can be said is that several hormonal disorders reinforce each other like in a hormonal vicious circle. One of the basic endocrinological constellations to be found, is the increased release of Luteinizing Hormone (LH) and a reduced release of Follicle-Stimulating Hormone FSH from the pituitary gland.

LH stimulates the production of male hormones, from which female hormones (estrogens) are then produced in a second step. With PCO syndrome, the increased LH level leads to an unnatural increase in male sex hormones. These male hormones are converted into estrogens and released against the normal menstrual cycle.

Due to the continuously high LH levels in the cycle, the oocytes are exposed to LH at an early stage, which, amongst other things, is responsible for triggering ovulation. They remain immature, cannot mature to the normal size of an egg follicle (approx. 25mm) and no normal occurring ovulation is often the case.

The increased level of male hormones can lead to a thickening of the outer wall of the ovary and lower levels of sex hormone-binding globulin, an important binding protein in the blood that normally binds some of the active male hormones and thus makes them ineffective, are also typical.

Is PCO syndrome hereditary?

Yes, studies with families indicate inheritance in PCO syndrome. They have shown that 52% of mothers, 21% of fathers and 55% of siblings of PCO syndrome patients also had a PCO-like type.

The Diagnosis

Three symptoms are decisive for the diagnosis of PCO syndrome: If two of the three so called “Rotterdam criteria” apply, polycystic ovarian syndrome is present:

- Irregular period or complete absence of ovulation and infrequent or absent ovulation.

- The level of male hormones in the blood is elevated and/or increased hair growth.

- The ovaries are surrounded or enlarged by many small cysts.

In a conversation with the patient, the doctor finds out whether the criteria of the cycle disorder applies- a physical examination clarifies the external symptoms and a vaginal ultrasound examination shows the condition of the ovaries.

If there are more than twelve small cysts (polycystic ovaries) which string together like pearls, the diagnosis of PCO syndrome is obvious.

In addition, the doctor checks the hormone levels with blood tests. It is typical for PCO that both the LH level (luteinizing hormone) and the values for male hormones as well as for the milk-forming hormone prolactin are strongly elevated.

The doctor can determine whether the described insulin resistance is present by a sugar test. To make sure that an increased androgen level is due to overproduction in the ovaries and not in the adrenal glands, the doctor carries out a so called dexamethasone test.

Treatment

There are many prejudices and misjudgements about PCO syndrome and they seem to be particularly persistent. The most common ones are statements like: "Try losing weight and it'll take care of itself!" ,"If you don't take the pill, you can get cancer!" or "The cysts must be surgically removed!". But it's important to know, that the syndrome of polycystic ovaries is a complex disorder that does not allow general standard therapy.

The diagnosis of PCO syndrome is not a medical "catastrophe" if certain preventive medical aspects are taken into account. If the increase in male hormones or the cycle disorder is the decisive problem, a contraceptive pill with an anti-androgenic component is currently used. This is a pill with a gestagen that regulates male hormones in the blood. The pill is also used to substitute estrogens (due to the frequent lack of female hormones) and to suppress increased male hormones. In addition, a permanent thickening of the lining of the uterus is prevented, as regular bleeding occurs due to the administration of the pill.

In case of overweight, weight reduction is necessary. In this context, reduction of carbohydrates is of central importance, because women with this hormone disorder particularly utilize carbohydrates and convert them into fat easier.

Women who have been diagnosed with the PCO syndrome might also be familiar with metformin, a tested medication used in health care to treat diabetes through absorption of sugar from the intestine and the following increase of insulin sensitivity.

References:

Greenwood, et al. (2016). Vigorous exercise is associated with superior metabolic profiles in polycystic ovary syndrome independent of total exercise expenditure.

Fertility and Sterility, 105(2), 486-493. Hart, R. J. (2016). Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics.

Physiological Reviews, 96(3), 873-909. Teede, et al. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertility and Sterility.