When I learned of Polycystic Ovary Syndrome (PCOS) more than 40 years ago, it was called Stein-Leventhal Syndrome. It had been named after Drs. Irving Stein and Michael Leventhal who noticed a pattern among some of the infertile women with menstrual irregularities.
They described seven women who exhibited three characteristics including “polycystic” ovaries, hirsutism (excessive hair growth), and amenorrhea (no menstrual periods) that we associate with PCOS now.
I recently read an article about PCOS that I will summarize here:
The cysts that Stein and Leventhal described are really immature antral follicles which are fluid-filled areas of the ovaries where eggs should mature. The polycystic name suggests that ovarian cysts are the defining feature of PCOS. But, except in teenage girls, the anatomy of the ovaries is not the most important feature used to diagnose the condition. Similarly, a woman with polycystic ovaries, but no hormonal or metabolic abnormalities, does not have PCOS.
It is estimated that as many as 10% of women may be affected by PCOS, although many remain undiagnosed. PCOS is also a diagnosis of exclusion. Other conditions with overlapping features like Cushing syndrome, male hormone-producing tumors, medications with male hormone-type side effects and congenital adrenal hyperplasia must first be ruled out before concluding that a woman has PCOS.
Some diagnostic criteria put more emphasis on the hormonal and metabolic features and less on ultrasound findings. But currently, the most widely accepted criteria for PCOS are the Rotterdam criteria, which state that PCOS can be diagnosed when two out of the following three criteria are met:
• Rare or no egg production
• Clinical or laboratory evidence of androgen (male hormone) excess
• Polycystic ovaries
Some patients with PCOS have regular menstrual cycles, but up to 90% have more than 35 days between cycles or have fewer than nine cycles annually. Hyperandrogenemia (elevated free testosterone, free androgen index, or DHEA levels) and/or clinical evidence of androgen excess (hirsutism, acne, clitoromegaly, male body appearance characteristics) are present in up to 80% of affected women.
Polycystic ovaries are defined as having 12 or more small follicles per ovary, but some authors suggest a much higher number.
Although not diagnostic, certain findings are more common in women with PCOS, including obesity, elevated luteinizing hormone levels, insulin resistance, impaired glucose tolerance, type 2 diabetes, dyslipidemia (too much fat in the bloodstream), hypertension (high blood pressure), abnormal blood vessel lining function, hypercoagulability (increased clotting tendency) and thickening of the uterine lining.
Some affected women have expressed frustration with the process of evaluation and diagnosis that they underwent to find out what was wrong with them. In recent crowdsourced data, one-third of women reported that it took at least two years to be diagnosed with PCOS, and almost half saw three or more healthcare professionals along the way. Diagnosis is most challenging in teenagers and perimenopausal women.
PCOS is the most common cause of female infertility. The lack of ovulation is not the only strike against fertility. But, if the rest of the evaluation is normal, regular ovulation must be restored to improve fertility.
Among overweight or obese women, weight loss should be the first-line treatment. The loss of as little as 5% of body weight can have a favorable effect on ovarian function. For women who do not conceive after lifestyle intervention, metformin (an insulin-sensitizing drug) has been shown to improve ovulation and live birth rates.
Drug therapy with Clomiphene is the recommended first choice for ovulation induction, successfully inducing ovulation in up to 80% of women with PCOS. Other drugs (and even surgery) may also be helpful, but can produce too many eggs and create multiple-gestation pregnancies.
The health consequences of PCOS are not limited to a woman’s childbearing years. The risk is increased for insulin resistance, diabetes, and/or metabolic syndrome. It is therefore recommended to screen women with PCOS (especially those with excess weight) with an oral glucose tolerance test and lipid profile.
Cardiovascular disease (CVD) risk factors and obesity are significantly more common with PCOS than in women without PCOS. However, it is not certain whether these risk factors translate into increased CVD illness or death.
Recent data suggest a threefold increased risk for endometrial cancer among women with PCOS, as well as an increased risk for ovarian cancer. But there may be hope for this tendency since preliminary findings suggest that insulin-sensitizing medications, like metformin, might be able to play a role in the prevention or treatment of these cancers.
If you are concerned that you might have PCOS, discuss evaluation and treatment with your healthcare provider.