The Polycystic-Ovary Syndrome (PCOS)

What is PCOS?

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

➜ Learn how women with PCOS are using the Pearl App to track their hormone levels.

What are the symptoms of PCOS?

The most common symptom of PCOS is increased male hormone, or androgen levels. Increased androgen levels can cause acne, greasy skin, increased and unwanted body hair growth, and accelerated hair loss in the scalp.

Another consequence of this hormonal disorder is irregular ovulation and subsequently irregular menstrual cycles. Delayed puberty is also typical in this context and happens to many women with PCOS. Other 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.PCOS can be found when looking at an ultrasound image with many small follicles, which can appear like a string of beads. Sometimes, a PCOS diagnosis may happen during a laparoscopic procedure.

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

What is causing PCOS?

The exact causes of the syndrome are unclear, but it is believed that several hormonal disorders reinforce each other in a vicious circle. One of the basic endocrine disturbances 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. With PCOS, the increased LH levels lead to an unnatural increase in male sex hormones. These male hormones are then converted into estrogens and released out of sync with the normal menstrual cycle.

Due to the continuously high LH levels during the cycle, the oocytes are exposed to LH at an early stage, which, among other things, is responsible for triggering ovulation. Because of this the eggs remain immature, never reaching the size of a mature follicle and thus preventing ovulation from happening. The increased level of male hormones can also lead to a thickening of the outer wall of the ovary and lower levels of sex hormone-binding globulin, an important binding protein. Sex hormone-binding globulin normally binds some of the active male hormones and thus makes them ineffective.

New research has also pointed out the key role of AMH (anti mullerian hormone), which plays an important gender-forming role in the development of the fetus. There’s a direct correlation between the AMH concentration and the number of mature eggs. New research actually suggests that elevated values of AMH are an indication of Polycystic Ovarian Syndrome.

A study published in the Journal of Clinical & Diagnostic Research for example, found that AMH levels were significantly higher in women with PCOS and that the measurement of AMH can be used as a marker of PCO.

Is PCO syndrome hereditary?

Yes, studies of families indicate inheritance in PCOS. 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 Official 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 diagnosed:

**-**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 gynaecologist finds out whether the criterion of cycle disorders 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 with a diameter of two to nine millimetres that also string together like pearls, the diagnosis of PCO is made.

In addition, the doctor may check the hormone levels with blood tests. It is typical of PCO patients to have both elevated LH levels and male hormones levels as well as for the milk-forming hormone prolactin to be strongly elevated. The doctor can determine whether insulin resistance is also present by means of a sugar test. To make sure that an increased androgen level is due to overproduction of hormones in the ovaries and not in the adrenal glands, the doctor can order a dexamethasone test.

Treatment

There are many prejudices and misconceptions about PCO syndrome seem to be particularly persistent. The most common are statements such as: "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." It’s important to know that the syndrome of polycystic ovaries is a complex disorder that cannot be treated by general standard therapy. Nevertheless, the diagnosis of PCO syndrome is treatable if certain preventive medical steps are taken.

If the increase in male hormones or the cycle disorder is the decisive problem, a contraceptive pill with an anti-androgenic component can be 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.

For people with high BMI and weight gain, 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 PCO syndrome might also use metformin. Metformin is a tested medication used to treat diabetes through absorption of sugar from the intestine resulting in increased 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.