Polycystic Ovarian Syndrome (PCOS) – The Basics

Polycystic Ovarian Syndrome, called PCOS, is the most common hormone disorder affecting women in the United States. As many as 10% to 15% of women have PCOS, and it plays a significant role in infertility diagnoses.

Notice it’s labeled a syndrome? This means that while we recognize its symptoms, and we know how it affects the body and inhibits reproduction, we aren’t really sure why it occurs. Thus, for now, PCOS is considered a syndrome, rather than a disease.

If you are young, and have a confirmed PCOS diagnosis, do your best to maximize fertility at home, but know that assisted reproduction may be required to facilitate your pregnancy. If you are 30-years old or older, and have PCOS, we recommend consulting with a fertility specialist to learn more about optimizing fertility and to discuss fertility treatment options.

Diagnosing PCOS

Women with PCOS have at least two of the following three symptoms:

  1. Irregular or absent menstruation.
  2. Extra hair growth and/or high free testosterone levels.
  3. An abundance of small ovarian cysts.

Let’s take a closer look at each one:

Symptom 1: Menstruation is Irregular or Absent (oligomenorrhea or amenorrhea)

A “normal” menstrual cycle ranges from about 21 to 35 days, with the average cycle being 28-days in length. Irregular periods, (called oligomenorrhea), cycle between 35 and 199 days. If you regularly go 200 days or more without menstruating, you have what is called amenorrhea – or an absence of menstruation.

In either case, it these menstrual irregularities are signs that your body isn’t ovulating and, if you aren’t ovulating, there is no egg available to be fertilized.

Symptom 2: Male Pattern Hair Growth (hirsutism)

Both women and men have roughly the same number of hair follicles. However, hormones determine whether those hair follicles are stimulated or not. Higher testosterone levels, for example, are required for the growth of a mustache or beard.

The ovaries in women with PCOS produce excess testosterone and so 70% of women with PCOS have what is called “excessive male pattern hair growth” on the face (hirsutism). This often expresses in the form of a thicker-than-normal mustache or even a beard. The facial hair may require daily shaving, routine waxing or electrolysis to remain hidden. Excess testosterone can also cause male-pattern baldness (alopecia) and acne.

This is not to say that women with hirsutism, alopecia and/or acne have PCOS. They are simply signs of higher-than-normal free testosterone levels. In most cases, facial hair is a good predictor of PCOS but thinning hair/baldness or acne are not.

Notice that we use the term “free testosterone levels?” If you have a blood test to evaluate hormone levels, a general practitioner will typically order results for “total testosterone levels.” However, with PCOS, we are more interested in free testosterone levels. So, if you suspect you have PCOS, let your GP know you want the lab results from your blood test to include free testosterone levels.

It’s also important to note that certain ethnicities have less, or more subtle, facial hair than others. For example, a woman of Southeast Asian decent may have PCOS, and higher free testosterone levels, but lack any signs of excess facial hair. This is one example of why a blood test can be very important in determining a PCOS diagnosis.

Symptom 3: An Abundance of Small Ovarian Cysts

The third symptom, and the one from which the syndrome drives its name, is an abundance of small cysts located on the outside of the ovaries. These PCOS-appearing cysts are very recognizable due to their resemblance to a pearl necklace, only it’s one that is comprised of little cysts.

Transvaginal ultrasounds, as opposed to abdominal ultrasounds, provide the best means of getting a good look at these cysts. The wand used for transvaginal ultrasounds is able to get much closer to your ovaries. We always do a transvaginal ultrasound on our patients to get the closest and most accurate ovarian image possible.

So, remember: women must have two of these three symptoms to be diagnosed with PCOS.

The Connection Between PCOS and Obesity

There is a distinct correlation between PCOS and obesity. In fact, 80% to 90% of women with PCOS are obese, with a body mass index (BMI) of 25 or higher. This does not mean that all obese women have PCOS, and there are also PCOS patients who are quite slim. However, there is a reason for the correlation between high BMIs and PCOS.

In cases where an obese woman has PCOS, the cause is typically due to excessive blood insulin levels. These levels are determined by a fasting blood sugar level greater than 126 ng/dL. Chronically high insulin levels poison the ovaries, causing them to produce extra testosterone, and this inhibits the normal estrogen-progesterone cycle required for ovulation. That cycle imbalance combined with excess testosterone is also responsible for excess hair growth and irregular or absent menstruation.

As a result of this insulin resistance, women with PCOS are at higher risk for:

Fertility Treatments for Women with PCOS

There is no singular or specific treatment for PCOS. However, there are things women with PCOS can do to improve their health, potentially minimize the symptoms of PCOS and to increase their chances of fertility.

Consume a Low-Carb Diet

As you can imagine, carbs are the enemy for women who have PCOS and insulin resistance, because elevated blood sugar levels create a vicious cycle. Consider the way blood sugar and insulin work together in a healthy woman: he eats carbohydrates, which are converted into glucose (sugar). The pancreas responds by producing exactly enough insulin to move that glucose out of the bloodstream and into cells, where it’s used as food. Her blood sugar levels return to normal.

For an obese woman with PCOS, it’s a little different. She has normal blood sugar levels but elevated insulin levels. When she eats carbohydrates, her pancreas produces more insulin – so now her high insulin levels elevate even higher. After the glucose is transferred from her blood to the cells, her insulin levels are still high, causing blood sugar levels to dip below normal. This tells the body, “We’re sugar hungry! Eat some more carbs to stabilize us.” The problem, of course, is that eating more carbs only makes things worse.

Most of our obese patients with PCOS are relieved to learn that their sugar cravings aren’t a sign of lack of will-power but, rather, a bona fide physiologic condition that can be helped via a low-carb diet.

Low-carb diets can be effective at bringing an obese PCOS patient’s health into better balance and improving fertility chances. Losing as little as 10% of your body mass can cause periods to become more regular, which means you’re ovulating, which increases your chances of conceiving.

Examples of low-carb diets include:

We recommend working with your general practitioner or fertility specialist to determine which of these diets or dietary changes make the most sense for you.

Also, keep in mind that sugary beverages are one of the worst things you can consume, causing rapid spikes in blood sugar levels, as well as insulin production. So, try to eliminate them from your diet altogether, replacing them with healthy, non-sugary alternatives.  You’ll also want to limit your consumption of pasta, bread, rice and processed foods and snacks. Information regarding the Glycemic Index and Diabetes can be helpful in planning meals and snacks.

Of course, a healthy lifestyle is always recommended when trying to get pregnant, so we recommend reading “Maximizing Fertility at Home” for more recommendations on living a fertility-friendly lifestyle.

Medication – Metformin

Metformin is commonly used to treat Type 2 Diabetes and it works to lower blood insulin levels. For a woman with PCOS, this can help the ovaries decrease testosterone production and get back to work producing estrogen and progesterone, making you more likely to ovulate.

While the original studies regarding metformin as a treatment for PCOS were promising, continued research has proved metformin to be a weak solution, so it’s not considered a “first-line treatment” for PCOS.

If you do want to give metformin a try, use the time-release option to limit the side effects, which include stomach upset and diarrhea. If your insurance doesn’t cover the time-release version, wean yourself on to the standard version by taking a 25% dose for the first week, 50% the second, 75% the third and then the full dose by the fourth week. This can help your stomach make a more comfortable adjustment.

Fertility Treatments

The fertility treatments for PCOS mimic fertility treatments for other infertility diagnoses. Refer back to “Fertility Treatments: Pills, Injections and IVF” for more detailed descriptions of each.

  1. Clomid or Letrozole. These are fertility pills, that can induce ovulation by stimulating the pituitary gland to produce follicle stimulating hormone (FSH). This can help to trigger the release of a mature egg (ovulation).Fertility pills can be used in conjunction with metformin, which supplies a gentle kick in the right direction. While metformin has shown to provide weak help, we operate under the premise that weak help is good help, and it is certainly better than no help.
  2. Controlled Ovarian Hyperstimulation (COH). Let us start with the disclaimer: We do NOT recommend the use of COH for most women with PCOS because it increases the risk of a multiples pregnancy. COH uses injectable fertility medication and packs a powerful punch, infusing the body with a specific dose of FSH that bypasses the brain altogether. The injection directly stimulates the release of mature eggs. However, women with PCOS can yield as many as 20 or 30 mature eggs via COH. That is a recipe for a multiples pregnancy that yields triplets, quadruplets or even more.You know those women in the mall pushing triplets around in the huge stroller? Those women typically used COH to get pregnant. We prefer to start with pills, which yield one or two eggs at a time, rather than injectables, to be on the safe side.
  3. In Vitro Fertilization (IVF). If Clomid and Letrozole were unsuccessful, we recommend patients with PCOS skip to IVF, where embryo transfer, and the quantity of embryos transplanted, is controlled. For IVF, we so use COH to retrieve matured eggs. Then we fertilize the eggs in the lab, freeze the embryos at exactly the right time and implant them later.

Special Considerations For PCOS Patients Who Choose IVF

Why use frozen embryos rather than fresh if you have PCOS? There are two reason.

First: With the use of COH comes the risk of more severe Ovarian Hyperstimulation Syndrome (OHSS). OHSS can continue throughout pregnancy. So, to avoid that risk, we wait a little allowing any symptoms of OHSS to recede before transferring an embryo.

Second: By waiting a bit before transferring the embryos, we reduce the rise of embryo–endometrial dyssynchrony. In the case of a natural conception, maturing ovarian follicles cause progesterone levels to go up a little bit before ovulation. Progesterone levels then peak five days later. This five-day cycle allows the endometrium (the uterine lining that provides the baby’s blood supply) to ripen in time for the embryo. Thus, most embryos implant about five days later, and all is well.

When we use COH, each of the stimulated ovarian follicles produces a little bit of estrogen. If OCH stimulates dozens of follicles, all those “little bits” add up to a lot, and this causes the endometrium to ripen faster than normal. If the endometrium ripens three days after ovulation, but the embryo can’t be transferred for five days, the endometrium says, “You’re late!” and the embryo doesn’t implant.

This is a fairly new discovery; 10 years ago, young women who used COH and had beautiful embryos would struggle to get pregnant when we performed a fresh embryo transfer. Then, about seven years ago, we began to realize what was going on. As a result, we now recommend using frozen embryos, and transferring the embryos at a future cycle date, so embryo transfer and the ripening of the endometrium are more likely to be in sync.

Potential Complications for Women with PCOS

As we mentioned above, women with PCOS are at risk for future health conditions, some of which can occur during pregnancy.

If you suspect you have PCOS, visit your OB/GYN so a diagnosis can be confirmed. If you do have PCOS, and you are interested in becoming pregnant, scheduling a consultation with a fertility specialist can significantly increase your fertility chances.

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