What is PCOS?
Ovulation involves the release of an egg from an ovary into the fallopian tube once a month. Before the release, the egg develops inside the ovary in a small swelling called a follicle. Every month multiple follicles will develop but usually only one egg will mature and be released.
This process is regulated by hormones. Polycystic Ovary Syndrome (PCOS) occurs the imbalance of certain hormones cause the development of multiple small immature follicles that remain in the ovaries (these can be seen on ultrasound scan).
The result of multiple immature follicles varies. For some women, an egg will still be released irregularly and for others no egg will be released (anovulation). It is important to take contraception to prevent unwanted pregnancy.
Polycystic ovary syndrome is very common and impacts approximately one in seven women during their reproductive years. Although the name suggests the disease would be of ‘cysts’ in the ovary, what is seen in the ovaries are multiple follicles (as discussed above). There is no link between true ovarian cysts and the multiple follicles that are seen in PCOS.
Many women will have polycystic ovaries but not experience the symptoms that are associated with PCOS.
The cause of PCOS is unknown, it is thought to be a combination of factors, including genetic, hormonal and lifestyle factors.
What are the symptoms of PCOS?
Symptoms of PCOS will vary throughout a woman’s life and will vary from woman to woman. In general, symptoms tend to start in a woman’s early twenties. The symptoms can include:
- Irregular periods or no periods
- Excess hair body hair growth
- Acne and oily skin
- Weight gain
- Difficulties getting pregnant
- Increased risk of diabetes
- Thinning of hair on the scalp
Diagnosis of PCOS can be hard as many other conditions appear similar to PCOS. When seeing a doctor, they may suggest multiple tests to exclude other conditions before a diagnosis of PCOS is confirmed.
Diagnosis is based on the three points below:
- A pattern of irregular periods or no periods at all.
- Higher levels of ‘androgen’ hormones. Androgen hormones are produced by all women, however high levels of androgen hormones are seen in women with PCOS. This can be diagnosed formally by blood test or informally by the pattern of symptoms such as acne, excess body hair and weight gain.
- On an ultrasound scan of the ovaries, over 12 follicles will be seen.
Management of PCOS
The risk of developing health problems that are associated with PCOS is greatly increased if you are overweight. Lifestyle changes that include regular exercise and a healthy balanced diet will result in weight loss and improvement of PCOS.
Weight-loss medication may be available if your doctor believes it would be beneficial in combination with lifestyle changes.
Cutting down and stopping smoking is advised in all women who are diagnosed with PCOS. Your GP will have links to local NHS Stop Smoking Service, there is also a Smokefree National Helpline on 03001231044 where anyone looking to stop smoking can speak to a trained advisor.
In regards to excess hair growth and the hair loss that may be experienced by women suffering from PCOS there are various treatments, including medications, that are available via your doctor. Different treatments such as laser hair removal may be available on the NHS in certain parts of the UK.
PCOS and Insulin
In addition to having higher androgen hormones, women with PCOS may have a higher level of insulin. During the diagnosis of PCOS a measurement of blood sugar level will be taken as a screening test to assess the potential risk of type 2 diabetes.
Insulin is a hormone that controls blood sugar levels in the body. Women with PCOS are more resistant to the action of insulin and therefore produce higher levels of insulin. The higher level of insulin can in turn cause the ovaries to produce more androgen hormones which in turn increase the hormonal imbalance seen in PCOS.
This higher level of insulin can cause weight gain which is associated with the development of Type 2 Diabetes. Women with PCOS will be screened regularly for Type 2 diabetes. Diagnosis is via a blood test and patients will be started on appropriate treatment as soon as possible as this reduces the risks of other associated health issues.
Treatment of Type 2 Diabetes will involve a multidisciplinary team. This management plan may include:
- Medications prescribed by your GP to manage your sugar levels
- Lifestyle changes including weight loss to improve insulin resistance, this may be supported by specialist dietician input.
- Regular Type 2 diabetes check-ups
- Diabetes education, some GP surgeries offer free education courses
PCOS and Fertility
PCOS is one of the most common but treatable causes of fertility issues in women.
Around 70 percent of women with PCOS may have issues with becoming pregnant. There are many complex causes as to why fertility may be decreased. This includes the imbalance of hormone levels impacting ovulation and lifestyle factors including increased body weight.
There are many options that can aid fertility in women with PCOS.
Firstly, lifestyle changes. It is thought that the most effective treatment for women with PCOS who have a BMI over 30 is weight loss by a healthy diet and exercise. In some cases, healthy lifestyle changes and weight loss alone can promote ovulation. It also allows medication to work more effectively.
Medications that can be used in combination with lifestyle changes include Clomifene. Clomifene is a tablet that is taken orally once a day. It causes hormone release and in turn prompts ovulation.
In some cases, Clomifene will be used with Metformin. Metformin is a medication that is traditionally used in patients with Type 2 Diabetes. In women with PCOS it works similarly to decrease insulin and blood sugar levels. The use of Metformin as a fertility treatment for women with PCOS is an ‘off label’ licence and your doctor will discuss this with you in detail.
If despite lifestyle changes and oral treatment you are unable to get pregnant you can be referred to a fertility specialist. Other options that may be considered may include minor ovarian surgery and IVF.
Ovarian surgery may be offered if deemed appropriate by a fertility specialist if medical options have been unsuccessful. This surgical technique is often called ‘laparoscopic ovarian drilling’ or ‘ovarian diathermy’. Under general anaesthetic, a small laparoscope will be inserted into the lower abdomen through a small incision. A laser will then be used to target tissue in the ovaries that is producing androgen hormones. LOD has been found to help correct the hormone imbalance that impacts ovulation.
PCOS and Pregnancy
Women who have PCOS in pregnancy are at a higher risk of complications including high blood pressure, gestational diabetes (diabetes during pregnancy), pre-eclampsia.
These risks are higher in women with a BMI of over 30 and therefore risks can be lowered by lifestyle changes before pregnancy.
Due to the increased risks, you may be seen by your doctor more regularly during your pregnancy and monitored more closely by your midwife.
Women with PCOS are more likely to experience emotional challenges to their wellbeing such as depression and anxiety.
Similarly to any other chronic condition, PCOS cannot be cured and therefore over time women can find it difficult to cope with the symptoms and stresses that are associated with having PCOS.
Alongside this, struggles with fertility and undertaking fertility treatments can impact on mental health and wellbeing.
It is important that if you are experiencing any symptoms of low mood or anxiety that you seek advice from your GP.
Support networks for women with PCOS can be invaluable, for some this is their friends and families. For others this may include healthcare professionals such as their GP, nurse and dietician.
There are many online support groups for women managing PCOS including:https://www.verity-pcos.org.uk/