Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a disorder caused by hormonal imbalance. Due to these imbalances, women who have PCOS may not get periods regularly or have longer than average cycles. The ovaries can develop cysts or small collections of fluid in the follicles which causes anovulation (failure to ovulate.)[1]

PCOS Symptoms

While the cause of PCOS is unknown, there are several symptoms to watch for:

Irregular periods. The average cycle is 28-30 days. Usually women with PCOS have eight or fewer periods a year (>35 days) with some women not having one at all. Additionally, some women may get them too often (at or around every 21 days.) Heavy bleeding, called menorrhagia, can also occur.
Extra hair on the face, chin, back or chest. Called “hirsutism”, this is due to the excess androgens (male hormones) that PCOS creates. According to the American College of Obstetricians and Gynecologists (ACOG), 70% of women with PCOS have this condition.[2]
Severe acne. This is also due to excess androgens produced by the ovaries.
Thinning hair. Due to androgens, women with PCOS may experience “male-pattern baldness.”
Weight gain or difficulty losing weight. According to the ACOG, up to 80% of women with PCOS are overweight or obese.
Areas of darkened skin. The patches, called acanthosis nigricans, are usually thick and velvety.

PCOS Diagnosis

To be diagnosed with PCOS, two or more of these side effects must be observed. PCOS can be diagnosed via various tests your doctor will perform. These include:

A physical exam in which a doctor will check for high blood pressure, body mass index (BMI), and for extra hair and darkened skin.
A blood test in which your doctor will check your androgen hormone levels as well as other areas, such as insulin and cholesterol.
A pelvic ultrasound in which the doctor will look for cysts on the ovaries or any problems with the lining of the uterus (endometrium.)[3]

Unfortunately, there is no cure for PCOS, but symptoms can be managed by losing weight, eating healthy, exercising regularly and quitting smoking.

PCOS Treatment

Birth control pills (BCP) are a treatment option for those who do not wish to become pregnant. BCP contains estrogen and progestin, which can reduce androgen levels to combat excess hair and acne.[4]

For those who do not want to use BCP, metformin is a possible option. As insulin resistance and high levels of insulin are side effects of PCOS, metformin, a drug used to improve glycemic control in those with type 2 diabetes or PCOS, can be used. Metformin is effective for treating the lack of ovulation; once the body ovulates, regular periods can soon follow.[5] However, metformin is not a long-term solution and it is still recommended to modify your lifestyle along with metformin use.[6]

PCOS and Infertility

The most common cause for female infertility is PCOS. In the case of non-ovulation (anovulation), PCOS accounts for around two thirds of them. PCOS also occurs in about one in every seven women of reproductive age.[6]

Although the presence of PCOS can make it harder to attain pregnancy, this does not mean it is impossible. A natural pregnancy is still possible when the body releases an egg on its own. However, other treatments, ranging from simple to more complex, currently exist for women with PCOS.

Clomid (clomiphene citrate) – Clomid is an anti-estrogen drug that stimulates ovulation. For more information on Clomid, please visit the “Ovulation Inducing Drugs” page.
Metformin – although also a regular treatment, metformin can help regulate insulin levels and produce ovulation. Studies have shown that Clomid and Metformin together can increase clinical pregnancy rates in women with PCOS.[7][8]
Femara (Letrozole) – Femara is also an ovulation stimulation drug. Usually Femara is used after repeated Clomid failures. For more information on Femara, please visit the “Ovulation Inducing Drugs” page.
Injectibles – After Clomid and Femara failures, your doctor may prescribe gonadotropin injections to stimulate ovulation. Gonadotropins contain either the luteinizing hormone (LH), follicle-stimulating hormone (FSH), or a mixture of both. These hormones, which are naturally produced by the pituitary gland, may be lacking in normal amounts in those with PCOS. These injections encourage the body to produce multiple follicles on the ovaries.[9] Typically these drugs are used in tandem with other assisted reproductive techniques, such as intrauterine insemination (IUI) or in vitro fertilization (IVF).

Ovarian Drilling

Also known as laparoscopic ovarian drilling or diathermy, this is a surgery that can help ovulation for women with PCOS. This is usually a last ditch effort for women who have failed previous treatments, but have still not tried IUI or IVF.

In women with PCOS, the ovaries are usually covered in a thick outer coating. In this treatment, a small camera is inserted into a small incision near your belly button to give a close view of the ovaries. Special tools are then used to drill into the thick outer surface. By doing this, the amount of androgens and testosterone created by the body will be reduced. With less testosterone created, the body at produce a regular period, thus inducing ovulation.[10]

However, ovarian drilling is not an ultimate solution. The thick coating may grow back or your cycles may become irregular as the months pass. According to one study, 20-30% of non-ovulating PCOS women fail to respond to ovarian drilling.[11] There are also risks to invasive surgery, no matter how minimal – injury to the bladder or intestines may occur or scar tissue can form between the ovaries and fallopian tubes.

Other Assisted Reproductive Technology (ART)

If all else fails, IUI and IVF are the following options after repeated failures. These processes are more invasive but may end in a pregnancy. Talk to your doctor to see if these options are right for you. For more information on either IUI or IVF, please visit their respective pages in the menu above.

[1] "Polycystic Ovary Syndrome (PCOS)." Mayo Clinic. August 29, 2017. Accessed April 16, 2018. https://www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439.

[2] "Women's Health Care Physicians." Polycystic Ovary Syndrome (PCOS) - ACOG. June 2017. Accessed April 16, 2018. https://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS.

[3] "Polycystic Ovary Syndrome." Womenshealth.gov. July 26, 2017. Accessed April 16, 2018. https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome#references.

[4] "Women's Health Care Physicians." Polycystic Ovary Syndrome (PCOS). June 2017. Accessed April 25, 2018. https://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS.

[5] Johnson, Neil P. 2014. “Metformin Use in Women with Polycystic Ovary Syndrome.” Annals of Translational Medicine 2 (6): 56. https://doi.org/10.3978/j.issn.2305-5839.2014.04.15.

[6] Lashen, Hany. 2010. “Role of Metformin in the Management of Polycystic Ovary Syndrome.” Therapeutic Advances in Endocrinology and Metabolism 1 (3). SAGE Publications: 117–28. https://doi.org/10.1177/2042018810380215.

[6] Hart, R. 2008. “PCOS and Infertility.” Panminerva Medica 50 (4): 305–14. http://www.ncbi.nlm.nih.gov/pubmed/19078871.

[7] Nestler, John E., Dale Stovall, Nausheen Akhter, Maria J. Iuorno, and Daniela J. Jakubowicz. 2002. “Strategies for the Use of Insulin-Sensitizing Drugs to Treat Infertility in Women with Polycystic Ovary Syndrome.” Fertility and Sterility 77 (2). Elsevier: 209–15. https://doi.org/10.1016/S0015-0282(01)02963-6.

[8] Misso, Marie L., Helena J. Teede, Roger Hart, Jennifer Wong, Luk Rombauts, Angela M. Melder, Robert J. Norman, and Michael F. Costello. 2012. “Status of Clomiphene Citrate and Metformin for Infertility in PCOS.” Trends in Endocrinology & Metabolism 23 (10). Elsevier Current Trends: 533–43. https://doi.org/10.1016/J.TEM.2012.07.001.

[9] Institute Health, PCOS. n.d. “Gonadatropin Injections.” Accessed April 25, 2018. https://pcos.com/gonadatropin-injections/.