Polycystic Ovarian Disease (PCOD)
What is Polycystic Ovarian Disease (PCOD, PCOS)?
Polycystic Ovary Syndrome (PCOS) is a common reproductive endocrine disorder, affecting about 5% of women.
In Polycystic Ovary Syndrome (PCOS), excessive amounts of androgens ("male" hormones such as testosterone) are produced by the ovaries. Polycystic Ovary Syndrome (PCOS) is a common cause of infertility, menstrual irregularity, and hirsute (excessive hair growth).
Definition of Polycystic Ovary Syndrome (PCOS)
Until very recently, the most widely accepted definition of Polycystic Ovary Syndrome (PCOS) was based upon the diagnostic criteria recommended in 1990 which classified Polycystic Ovary Syndrome (PCOS) as a disorder characterized by chronic hyperandrogenism (elevation of serum testosterone or other androgens) and chronic anovulation (absence of ovulation) in the absence of other specific causes of these problems.
More recently, an international consensus in 2003 expanded the definition of Polycystic Ovary Syndrome (PCOS) to include women who demonstrate two of the following three characteristics:
- Chronic anovulation
- Chronic hyperandrogenism
- Polycystic-appearing ovaries (PCO) on ultrasound
Without these criteria, a woman should not have a diagnosis of Polycystic Ovarian Disease (PCOD). Although, she may have irregular cycles, and "act" clinically like Polycystic Ovarian Disease (PCOD), her diagnosis is hypothalamic-pituitary dysfunction (HPD).
PCOS vs HPD
This distinction is important to make because Polycystic Ovarian Disease (PCOD) and HPD, although clinically similar in presentation and some long-term consequences, behave differently in response to fertility medication, egg and embryo quality, the risk of overstimulation, and OHSS.
Graphic presentation of a normal ovary and a polycystic ovary
Ultrasound picture of a "polycystic" ovary showing multiple ovarian cysts around the outer surface or capsule of the ovary.
Polycystic Ovary Syndrome (PCOS) Diagnosis
Women who have Polycystic Ovary Syndrome (PCOS) may have irregular, infrequent menstrual cycles, hirsutism, acne and/or infertility. Many, but not all women (50%) with Polycystic Ovary Syndrome (PCOS) have ovaries enlarged with many small cysts (fluid-filled sacs), that are visible on ultrasound. Polycystic-appearing ovaries are also seen in approximately 20% of women with normal menstrual cycles.
Because of the variable nature of Polycystic Ovary Syndrome (PCOS), its diagnosis is based upon the combination of clinical, ultrasound and laboratory features.
A hallmark laboratory sign of Polycystic Ovarian Disease (PCOD), is a reverse ratio of FSH to LH. These tests can easily be measured in the blood and normally show an equal ratio of FSH to LH or, FSH being slightly higher than LH. In Polycystic Ovarian Disease (PCOD), the ratio is reversed with a 3:1 of LH:FSH.
Polycystic Ovarian Disease (PCOD) ovaries (picture 1) are typically enlarged 2-3 times normal size and have a smooth surface without any signs of recent ovulation as compared to non-PCOD ovaries that are small and full of cervices and show signs of ovulation. At pathology, a cross-section of the ovary.
(picture 2) show multiple or "poly-cysts" right under the surface or capsule of the ovary.
A graphic representation of the path physiology of polycystic ovarian disease with elevated levels of LH (3x greater than FSH) stimulating increased androgen(testosterone) production by the ovary causing excess hair growth and acne. COD is also associated with glucose and insulin dysfunction resulting in obesity, increased risk of diabetes and abnormal lipid metabolism (elevated cholesterol) and hypertension. The increased androgen production blocks subsequent ovulation and causes the existing follicles to undergo degeneration or atresia.
Polycystic Ovary Syndrome (PCOS) Risks
PCOS and Endometrial Cancer Risk
Lack of ovulation in women with Polycystic Ovary Syndrome (PCOS) results in continuous exposure of their uterine lining (endometrium) to estrogen. This may cause excessive thickening of the endometrium and heavy, irregular bleeding.
Over many years, endometrial cancer may result due to the continuous stimulation of the endometrium by estrogen unopposed by progesterone, which is only produced if ovulation occurs.
Statistically, women with Polycystic Ovarian Disease (PCOD) are at a 4-8x higher risk for endometrial cancer than women with regular ovulatory cycles. The treatment for these women is either pregnancy; or if that is not an option, then regular withdrawal bleeds (every 1-2 months) with some progesterone agent.
PCOS and Metabolic Syndrome Risk
Women with Polycystic Ovary Syndrome (PCOS) may be also at increased risk for developing a metabolic syndrome, which is mischaracterized by abdominal obesity, cholesterol abnormalities, hypertension, and insulin resistance that impairs blood sugar regulation.
PCOS and Type 2 Diabetes Risk
Women with Polycystic Ovary Syndrome (PCOS) have an increased risk of developing Type 2 diabetes, and possibly heart disease too. Obesity is common in women with Polycystic Ovary Syndrome (PCOS). Diet and exercise that result in weight loss improves the frequency of ovulation, improves fertility, lowers the risk of diabetes, and lowers androgen levels in many women with Polycystic Ovary Syndrome (PCOS); and is, therefore, an important component of therapy. Increasing physical activity is an important step in any weight reduction program.
Polycystic Ovary Disease (PCOS) Treatments
If you are diagnosed with Polycystic Ovary Syndrome (PCOS), treatment will depend upon your goals. Some patients are primarily concerned with fertility, while others are more concerned about menstrual cycle regulation, excess hair growth (hirsutism), and/or acne. Regardless of your primary goal, Polycystic Ovary Syndrome (PCOS) should be treated because of the long-term health risks it poses.
If fertility is your immediate goal, ovulation may often be induced with clomiphene citrate (Clomid®, Serophene®), an orally administered fertility medication. Treatment with medications that increase your body's sensitivity to insulin, such as metformin (Glucophage®), may lead to more regular ovulation. Gonadotrophins may be used to induce ovulation if you do not respond to simpler treatments. Gonadotropin therapy, however, is more expensive and associated with a greater chance of multiple pregnancies and side effects than oral therapies but does have, statistically, higher success rates in a shorter period of time.
If fertility is not an immediate concern, hormonal therapies are usually successful in temporarily correcting the problems associated with Polycystic Ovary Syndrome (PCOS). Oral contraceptive pills (OCAs) are commonly prescribed to reduce hirsutism and acne, maintain regular menstrual periods, prevent endometrial cancer, and prevent pregnancy. OCAs may be combined with medications that decrease androgen action, such as spironolactone, to improve hirsutism. If OCAs are medically contraindicated, the treatment for these women is either pregnancy; or if that is not an option, then regular withdrawal bleeds (every 1-2months) with some progesterone agent to decrease the risks of endometrial cancer in 20-30 years.
A surgical procedure, known as wedge resection of the ovaries, where a portion of the ovary is removed to decrease the number of androgens produced by a Polycystic Ovarian Disease (PCOD) ovary, although having had good success, has been abandoned because of concerns about the formation of pelvic adhesions, resulting infertility, and loss of valuable ovarian tissue. Ovarian diathermy or laser drilling has been used in recent years with apparently good results; however, a recent systematic review comparing drilling with Clomid and gonadotrophins (HMG) proved equivalent and therefore, Arizona Center for Fertility Studies does not recommend ovarian drilling as a treatment for Polycystic Ovary Syndrome (PCOS).
Vaniqa® cream and spironolactone (a mild fluid pill) have been approved to reduce facial hair. Methods that remove hair, such as electrolysis and laser, are also helpful. Dealing with Polycystic Ovary Syndrome (PCOS) can be emotionally difficult. Women with Polycystic Ovary Syndrome (PCOS) may feel self-conscious about their excessive hair growth or weight, as well as worry about their ability to have children but there are a number of successful medical modalities that can effectively reduce the side-effects and achieve pregnancy.
The American Society for Reproductive Medicine