Polycystic ovary syndrome (PCOS) is a hormonal imbalance that occurs when the ovaries produce an excessive amount of androgens. It is a fairly common diagnosis among reproductive-aged women, affecting nearly 10% of this population. Many women wonder if PCOS is associated with infertility struggle or other symptoms, such as irregular periods, hirsutism, acne, and weight gain. Dr. Jasmine L. Chiang, MD, FACOG is an REI Physician at Conceptions Reproductive Associates (CRA) of Colorado, wrote this article to explore how PCOS is diagnosed and can be treated. Consider seeing your OBGYN for a consultation if you believe you may have PCOS.
Do I have PCOS?
The Rotterdam Criteria is frequently utilized to diagnosis PCOS. A patient must have two of the following:
- Hyperandrogenism (either clinical excess hair growth, or elevated Testosterone on bloodwork)
- Oligomenorrhea or Amenorrhea (irregular or absent periods)
- Inconsistent menstrual cycles where cycles vary by more than seven to nine days each
- Menstrual cycle length outside the range of twenty-one to thirty-five days per cycle One or both ovaries are “polycystic”
Note that there are many other causes of irregular cycles that should be ruled out prior to a diagnosis of PCOS such as:
- Thyroid disease
- Prolactin disorders
- Primary ovarian insufficiency
For this reason, it is important to seek out your OB/GYN or REI physician to make this diagnosis appropriately.
I’ve Been Diagnosed with PCOS and Am Trying to Conceive
Once a diagnosis of PCOS is made, it is important to clarify your goals. If you are trying to conceive, there are excellent options for fertility treatment available.
- Lifestyle Changes: the first step after a PCOS diagnosis is to change your lifestyle to help manage the disease. In obese women, weight loss, even as little as 5% of initial body weight, can improve a patients’ cycle regulation and pregnancy rates. So, if you have been diagnosed with PCOS, a great place to start is by asking yourself, “how can I improve my lifestyle?”
- Ovulation Induction: this process stimulates ovulation and creates regular periods. It is the cornerstone of treatment for PCOS and for many infertility patients. For many years Clomid (a fertility pill) was the first-line agent for PCOS. However, recent high-quality studies have shown that Letrozole (another fertility pill) has seen better ovulation rates, clinical pregnancy rates and live birth rates compared to Clomid. Both fertility pills have a similarly increased risk of twins and multiple gestations. Patients may either do ovulation induction with timed intercourse (sex at home), or with intrauterine insemination (IUI), depending on the presence of male factor diagnosis (low sperm count, patients using donor sperm to conceive, etc.).
- Gonadotropins: these fertility injections are another method of ovulation induction. These may sometimes be used with timed intercourse or IUI but are more commonly prescribed in conjunction with invitro fertilization (IVF). In IVF, fertility shots are given for eight to twelve days, followed by an egg retrieval. The eggs are then fertilized to create embryos which are implanted into the uterus when the patient is ready.
- Metformin is sometimes used in conjunction with ovulation induction. It may improve glucose tolerance in PCOS patients with prediabetes and may improve weight management in some patients. However, data are insufficient to prescribe Metformin universally, so the decision to utilize Metformin should be made in conjunction with your healthcare professional on an individualized basis. In IVF patients, there is also some evidence that Metformin can be used prior to an egg retrieval to reduce the risk of Ovarian Hyperstimulation Syndrome (OHSS).
I’ve Been Diagnosed With PCOS and Am Not Trying to Conceive
- Decrease Risk of Type 2 Diabetes: If you are not trying to conceive, it is still important to manage PCOS. A healthy lifestyle, including diet, exercise and weight loss if appropriate, is important to minimize the risk of developing Type 2 Diabetes. There is also some association with high cholesterol and cardiovascular disease. Because of this, it is important to ask your physician about Diabetes and Cholesterol screening, blood pressure, and weight checks to manage these risks.
- Decrease Risk of Cancer: PCOS with irregular menses also increases risk of uterine pre-cancer or cancer if irregular or absent periods are not managed over time. Therefore, it is important to manage irregular periods with your OBGYN physician. Cycles can be regulated using birth control pills (Estrogen + Progesterone), or Progesterone-only pills, which can be used to induce a period every 6-8 weeks. Cycles can be safely suppressed using Progesterone IUD’s, like Mirena, Kyleena, Skyla, Progesterone Implant devices, like Nexplanon, or Progesterone shots, like Depo-Provera. This is called “Endometrial Protection” and is of critical importance to reduce future risk of uterine pre-cancer or cancer from irregular or absent cycles.
- Treat Hirsutism and Acne: “anti-androgens” can be used to treat hirsutism and acne in woman with adequate contraception in place. These medications are daily pills, such as Spironolactone, Flutamide and Finasteride. Another option for the treatment of facial hirsutism in particular is Topical Eflornithine Cream, which is applied 2x daily to affected facial areas. Many of these agents can take 3-6 months to see full clinical effects, so patience is important.
Overall, PCOS affects many women throughout their lives. Education about PCOS is important, because when women are aware of these issues, they can manage them effectively and generally do very well. If you have questions about whether you might have this diagnosis and what it means, it is best to start the discussion with your OBGYN physician or a Reproductive Endocrinology and Infertility Specialist.
Resource: ACOG Practice Bulletin No. 194, Polycystic Ovary Syndrome