Introduction to PCOS
Although Polycystic Ovary Syndrome (PCOS) now affects around 7% of women in the UK of reproductive age, this syndrome still remains a mystery to many, including health professionals. There is still much controversy surrounding its cause and around which interventions work best.
Obesity, especially central adiposity (proportionally more weight being carried around the tummy), is present in around 40% of women with PCOS and a greater degree of obesity is associated with a more severe form of PCOS. There is also a higher incidence of metabolic syndrome (high blood pressure, high cholsterol and a tendancy towards diabetes) amongst women with PCOS than in non-PCOS overweight and obese women. Weight loss in the overweight/obese woman is therefore fundamental to treating the condition.
As nearly 90% of infertility cases attending infertility units are due to PCOS, women with this syndrome can improve their chances of falling pregnant and having a healthy baby if they address certin diet and lifestyle factors. There is no cure for PCOS, but adopting healthy lifestyle practices can control the symptoms caused by the syndrome and so much of the treatment for PCOS is in the sufferers own hands.
Polycystic Ovary Syndrome (PCOS) is the most common ovarian function disorder in pre-menopausal women. Around 1/3 of women in the UK have polycystic ovaries (PCO), but despite having small cysts on their ovaries, they don’t have any symptoms of PCOS. For actual PCOS, where definite symptoms are present, the incidence in women is between 5-10% and the rate appears to be increasing.
The differing array of symptoms which can present themselves in PCOS often makes an initial diagnosis of PCOS quite difficult. PCOS is often described as being a condition of hormone imbalances and it is believed to have a genetic basis. The development of PCOS may also be affected by the gestational environment and there may be foetal programming involved. It is thought that the rise in obesity may be acting as a trigger to PCOS in women with a genetic pre-disposition
Getting a diagnosis
Defining PCOS According to the American Society for Reproductive Medicine , PCOS is defined by having of any two of the following signs and symptoms:
• Lack of ovulation for an extended period of time
• High levels of androgens
• Many small cysts on the ovaries (normal ovaries have 5-6 follicles, whereas in polycystic ovaries there are ten or more). These cysts are immature follicles, the egg-containing structures in the ovary, one of which should grow monthly to release an egg, but this tends not to happen routinely, if at all in PCOS, resulting in impaired fertility.
To diagnose PCOS in teenagers, all 3 of the symptoms need to be present
The symptoms of PCOS tend to be different from woman to woman and can be present in any combination; the symptoms can also change over time and 20% of women with polycystic ovaries are symptomless.
Symptoms are more severe with weight gain and tend to diminish with weight loss.
The most common symptoms are:
• Weight gain, especially central adiposity; 40-50% of women with PCOS are overweight
• Central adiposity (waist circumference of over 80cms)
- Metabolic syndrome (11x increase risk in PCOS). Metabolic syndrome is characterised by symptoms such as high blood pressure, increase in inflammatory and clotting factors as well as insulin resistance
• Hirsutism which can occur in various places on the body, including the face
• Male pattern baldness or thinning hair,
• Oily skin with acne
• Absent or irregular menstrual cycles, leading to infertility. PCOS women with long intervals between periods have a greater degree of insulin resistance
• Depression, anxiety, irritability and mood swings. It is thought that these emotional symptoms are due to a combination of the hormone disturbances that occur, coupled with the fact that PCOS causes a host of upsetting symptoms resulting in stress involved in living with a long term medical condition
•Insulin resistance: 40% of women with PCOS go on to develop insulin resistance and it can lead to conditions such as diabetes and heart disease as a result of other effects in the body such as a rise in LDL and triglycerides and a lowering of protective HDL. Insulin resistance can also result in tiredness, lethargy and sudden drops in blood sugar levels in PCOS sufferers.
The hormones involved in controlling periods, and ultimately reproduction, are produced in the pituitary gland. In PCOS two of these: luteinising hormone (LH) and follicle stimulating hormone (FSH) are produced disproportionately and this is believed to cause the follicles in the ovary to not develop properly: they tend to remain small and do not mature enough to release an egg. This results in a string of small follicles forming on the ovary, which gives rise to the characteristic ‘string of pearls’ seen by ultra-sound of polycystic ovary. A high circulating level of insulin is common in PCOS and can be detected even in sufferers of normal weight.
Insulin resistance is seen in 10-15% of slim women with PCOS and 20-40% obese women with it. As well as contributing to weight gain, high levels of insulin drive the ovary to produce high levels of androgens; this causes many of the outward symptoms of PCOS such as the acne, thinning hair and hirsutism. However high androgen levels tend to be driven by LH in slim women with PCOS and not and insulin in overweight women.
Unfortunately there is no cure for PCOS but it can be controlled so that its effect on a woman is minimal. Treatment involves:
- Improving insulin sensitivity to prevent the whole cascade of later problems such as developing Type 2 diabetes and heart disease.
- Restoring normal ovulation and hence also fertility. (Reproductive outcome is best if BMI is reduced to less than 30 before drugs for ovarian stimulation are given)
- Preventing androgen levels from rising.
Treatment of PCOS therefore involves the three pronged attack of:
- Diet: using a weight control diet if necessary with low GI advice
- Exercise: encouraging more physically active on a day to day basis and throughout the day
- Ensuring emotional well-being and motivation to change lifestyle