Polycystic Ovary Syndrome

Polycystic ovary syndrome is a complex endocrine condition. The presenting problem should inform management options. These commonly include:

• Infrequent bleeding (reflecting infrequent ovulation)
• Symptoms of excess male hormones, including acne and facial hair
• Fertility problems

Women with PCOS do not always have subfertility and therefore contraception is important for women who do not wish to become pregnant.

Some women with PCOS have problems with their weight – weight reduction can have a pivotal role in the management of symptomatic women with PCOS.

Around 20% of women have polycystic ovaries, although only a small proportion of these will have symptoms of polycystic ovary syndrome.

What are polycystic ovaries?

This is not a good description, as there are no “cysts” on the ovaries, rather unruptured follicles, which contain an egg, capable of becoming a baby, if fertilised. If you have regular periods and are ovulating, usually one of your follicles will grow to about 20mm in diameter before releasing an egg, which then travels into one of your fallopian tubes. It is here that fertilisation occurs, before the fertilised egg travels into the uterus where it grows and develops as a pregnancy. Women with PCOS do not ovulate on a regular basis, which can affect fertility, although this is not always the case. Polycystic ovaries usually contain at least 12 small follicles or cysts that do not reach mature size. The ovaries are usually enlarged with more androgen producing tissue.

Producing eggs, capable of becoming a baby is an important function of the ovary. In addition ovaries produce hormones, which can influence well being. There are three main groups of hormones - oestrogens, progestogens and androgens.

The diagnosis is best made via a history – two out of the following three criteria are required for a diagnosis of polycystic ovary syndrome (Rotterdam Criteria):

The typical features on ultrasound - The small cysts represent unruptured follicles and do not require surgical removal or cause ovarian cancer

Infrequent periods reflecting infrequent ovulation

Symptoms of excess amounts of androgen, namely acne or excess hair (often affecting the face, nipples or lower abdomen).

There is some evidence of polycystic ovary syndrome running in families with a higher number of women from South Asia being affected.

How do we manage PCOS?

For overweight women, dietary advice with the introduction of high fibre, low fat and sugar diets, together and regular exercise, may help. Being overweight is a problem for women with polycystic ovaries as this promotes higher levels of androgens and increases the risk of insulin resistance, which is linked to diabetes.

It is best to manage the presenting problem, which may be fertility issues, bleeding problems or issues associated with excess androgens including acne or hairiness.

Subfertility

If ovulation is erratic it will take longer than normal to become pregnant. There are different treatment options available to stimulate ovulation including Clomifene taken orally, FSH injections and ovarian drilling (under general anaesthetic). Sometimes Metformin, a drug normally used to manage diabetes is recommended to be taken with Clomifene to help promote ovulation.

Irregular heavy bleeding

Combined hormonal contraception if eligible – pills, patch and vaginal ring. Other choices include intrauterine systems - Mirena®, Levosert ®, Jaydess® or  Kyleena®. The right one for you will be discussed during your consultation. Most women who have an IUS fitted feel some discomfort and you might want to take painkillers before the procedure or ask for a local anaesthetic.These options prevent the lining of the womb becoming too thick, which increases the risk of cancer.

If not using hormonal contraception, it is important to bleed every 3 to 4 months to shed the lining of the womb and prevent it becoming too thick. This can be induced with a prescription for a short course of norethisterone or provera.