Polycystic Ovary Syndrome

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Overview

PCOS is a hormonal imbalance that interferes with normal ovulation. Women with this syndrome don’t have a normal, regularly menstrual cycle. This hormonal imbalance affects other body systems such as metabolic and cardiovascular system. Most women with polycystic ovary shows numerous small cysts (smaller than a pea) in the ovaries in a certain period of time. However some women with PCOS don’t have polycystic ovaries, but symptoms of the syndrome.
 

Overview
Causes
Symptoms
Pathophysiological mechanism
Risk Factors
Watchful waiting
Medical specialists recommended
Investigations
Treatment – Overview
Initial treatment
Maintenance treatment
Prophylaxis
Home Treatment
Medications
Surgical treatment

Causes

Hormonal imbalance that occurs in polycystic ovary syndrome is not fully understood, but genetic factors seem to be involved. Daughters and sisters of women with PCOS have a 50% chance of developing the disease.
Abnormal production of insulin and metabolic disorders may contribute to PCOS. If you do not ovulate normally for a period of time you can develop multiple cysts on the ovaries (polycystic ovaries).

Symptoms

Many of the symptoms of polycystic ovary syndrome develop gradually and at first can be confused with other medical problems. May appear only a few symptoms or more.

Early symptoms

Early symptoms of PCOS include:
- Less than 5 menstrual cycles a year, more than 35 days between cycles or no menstrual periods. Failure to ovulate each month occurs in approximately 50% of women with PCOS
- Abnormal vaginal bleeding. This symptom occurs in about 30% of women with PCOS – hair growth in excess (hirsutism) on the face, chest, back, abdomen, fingers. More than 70% of women with PCOS complain of hair growth
- Skin problems such as acne, oily skin, dandruff, dark skin patches (acanthosis nigricans) on the neck, armpits or skin folds or folds of skin on the neck and armpits
- Depression or mood swings. Many women have emotional problems related to many symptoms such as excess hair, obesity and infertility

Late symptoms

Symptoms can develop gradually include:
- Pain in the lower abdomen and pelvis (chronic pelvic pain)
- Weight gain or upper body obesity (more than fat on the abdomen than the hips). This is known as type android obesity and is linked to increased levels of male hormones (testosterone)
- Infertility
- Symptoms of insulin resistance, which increases the risk of developing diabetes in women with polycystic ovary syndrome. About 30% of women with PCOS have impaired glucose functioning, and between 7% and 10% have type 2 diabetes. Some symptoms are associated with insulin resistance such as folds of skin and dark skin patches (acanthosis nigricans) and weight gain in upper body
- High blood pressure (hypertension)
- Male pattern baldness or thinning hair (alopecia)

Most women with PCOS present to a medical consultation for a specific symptom, not knowing that they have PCOS. The most common reasons women seek evaluation are:
- Menstrual problems
- Excess hair growth (hirsutism)
- Infertility
- Weight gain or upper body obesity

There are a number of conditions and diseases that have symptoms similar to polycystic ovary syndrome. They are:
- High levels of prolactin
- An excess of adrenal hormones. This high level may be present at birth (congenital adrenal hyperplasia) or may occur in adults, causing irregular menstrual cycles and excess hair growth (hirsutism)
- Cushing
- Tumors of the ovary or adrenal gland that produce male hormones
- Thyroid problems such as autoimmune thyroiditis, hypothyroidism or hyperthyroidism
- Food-related disorders

More regular menstrual cycles can occur in women approaching menopause. The reason for this is unknown. However, history of PCOS may increase long term risk for hypertension, heart disease, diabetes and endometrial cancer.


Pathophysiological mechanism

PCOS interferes with normal ovulation resulting in increased levels of male hormones that cause many symptoms. Irregular menstrual cause irregular ovulation cycles. Abnormal production of insulin and metabolic disorders contribute to the development of this syndrome.
Increased male hormones (androgens) in polycystic ovary syndrome lead to acne and abnormal hair growth (hirsutism). Many women with PCOS have many cysts on the ovaries (polycystic ovaries). A polycystic ovary is 3 times bigger than a normal ovary.

PCOS may increase the risk of developing other conditions and diseases over time, such as:
- reproductive problems. These could be:
- Irregular menstrual bleeding
- Miscarriage
- Preeclampsia
- Infertility
- Endometrial hyperplasia
- Endometrial cancer
- Metabolic problems. These may include:
- Insulin resistance
- Gestational diabetes
- Metabolic syndrome
- Type 2 diabetes
- Obesity.
- Cardiovascular problems. PCOS may increase the risk for cardiovascular problems such as:
- Coronary artery disease or myocardial infarction
- High blood pressure (hypertension)
- Cholesterol
- Atherosclerosis

Women with PCOS have a higher risk for sleep apnea than women without PCOS.
Research has not determined whether PCOS increases the risk for breast or ovarian cancer.


Risk Factors

The main factor for polycystic ovary syndrome is a family history of this syndrome. Sisters and daughters of women with PCOS have a 50% chance of developing disease.
A family history increases the risk for this syndrome because there is a strong relationship between diabetes and polycystic ovary syndrome. Research continues with respect to this risk factor.
Long-term treatment of epilepsy called valproate may increase the risk of developing PCOS.


Watchful waiting

Watchful waiting is not recommended when PCOS is suspected. Diagnosis and early treatment can prevent complications such as reproductive problems, metabolic and cardiovascular.


Medical specialists recommended

Doctors who can diagnose and treat polycystic ovary syndrome are:
- Gynecologists
- Obstetricians
- GPs
- Internists
- Endocrinologists
- Reproductive endocrinologists


Investigations

If you have less than 8 menstrual periods last year, except when you were pregnant or breastfeeding, you need to consult a doctor for evaluation PCOS or other hormonal problems. PCOS has a wide range of symptoms that can not be diagnosed with a single test.
The doctor will take a medical history and physical examination. History includes questions about menstrual cycles and lifestyle, including diet, weight changes, physical activity, how to deal with stress, and questions about family history and endocrine problems. Physical examination including a pelvic exam, bimanual pelvic exam to determine if the ovaries are enlarged or abnormal structure.
Examinations and tests to diagnose the syndrome may include:
- Calculation of body mass index, based on height and weight;
- Biochemistry tests to determine kidney function, liver and blood sugar levels;
- Human chorionic gonadotropin to confirm or rule out pregnancy;
- Level of male hormones (testosterone) to determine the cause of excessive or abnormal growth of hair (hirsutism);
- Adrenal hormones such as sulfate or 17-hydroxyprogesterone dehydroandrosterone to check if there is anything to cause symptoms of adrenal;
- Cholesterol and triglycerides in order to verify abnormal lipid levels.
Other tests may include:
- Glucose tolerance test to measure the body’s ability to use glucose
- Insulin levels can cause the body to produce insulin
- Testing of prolactin levels, because of the absence of menstrual cycles or infertility
- Tests for thyroid, including thyroid stimulating hormone to determine an underactive or overactive thyroid. A transvaginal ultrasound may be done to evaluate symptoms such as pain in the pelvis, but is not necessary to diagnose PCOS. An ovary with multiple cysts (polycystic ovary) is usually increased and has eight or more cysts, looking in the ultrasound like a necklace. Many women with PCOS will have cysts on the ovaries at a time. However, some women may have PCOS without an ultrasound appearance of polycystic ovaries and some women with PCOS may not have polycystic ovaries. Thus ultrasound is not necessary to confirm the diagnosis.
Can be made and additional testing to determine if there are other conditions that have similar symptoms, such as adrenal gland tumors.
If diagnosed with this syndrome is necessary to regularly monitor weight, blood pressure and menstrual cycles. Also, every year we test glucose, cholesterol and triglycerides. Regular testing reduces the risk of any long-term complications. Obese women with PCOS require measuring the glucose level more often than once a year, because obesity increases the risk of diabetes in women with polycystic ovary syndrome.

Treatment – Overview

Weight and metabolic problems that may occur in polycystic ovary syndrome are usually treated with medication and lifestyle changes. However, because this syndrome causes different symptoms and problems, treatment varies from case to case.
Treatment choice will focus on:
- Solve specific symptoms such as irregular periods, excess hair growth (hirsutism) or infertility
- Prevent long term complications such as weight gain, diabetes or hypertension
- Reduced risk for other medical conditions such as heart disease, high cholesterol or endometrial hyperplasia
PCOS is a chronic disease so that treatment can change throughout life.

Overview

Initial treatment

Initial treatment for polycystic ovary syndrome include:
- Regulate ovulation and menstrual cycles. Treatment for irregular menstrual bleeding or absent menstrual cycles consists of regular hormonal therapy (estrogen and progesterone) in the form of pills, vaginal ring or skin patch. If you can not use estrogen, progesterone pills may be recommended for the first 10-12 days of endometrial lining so as to eliminate similar with the menstrual period
- Reducing levels of male hormones. Treatment for excessive hair growth (hirsutism) may be the medication or its removal
- Treatment of skin problems like acne, using oral medication or local (topical) prescription or without. Treatment for skin folds is not necessary unless they are irritated, such as at the eyelid. Generally, they can be easily removed by a doctor
- Lifestyle change for weight control. Treatment for obesity focuses on diet, exercise and weight loss. Weight loss, even if only 5-7% within 6 months may reduce testosterone levels and return of ovulation and fertility in more than 75% of women with PCOS
Physical changes and reproductive problems of PCOS can affect the person’s body image. This image may increase the risk for stress, depression and an unhealthy lifestyle choice. And they may need treatment for their symptoms.
Teenagers are very conscious of the physical symptoms of PCOS, especially in excess hair growth, acne and weight gain. Early diagnosis and treatment of this hormonal imbalance can cause the elimination of these symptoms and prevent long term complications such as diabetes and infertility.

Women between 20 and 40 years with polycystic ovary syndrome are the most affected by the problems. Initial treatment for these women include menstrual cycle and ovulation induction.
For women aged over 40 years, treatment focuses on monitoring syndrome risk for heart disease and diabetes.

Maintenance treatment

Maintenance treatment for PCOS include medication and lifestyle changes. Treatment aims to eliminate symptoms and prevent long term complications. There is no cure for the syndrome, but most women can lead a healthy life with medical treatment and lifestyle changes.

- Infertility treatment focuses on the induction of regular ovulatory cycles. These may include fertility medication. Many women with PCOS may have regular cycles and conceive
- Treatment for infertility caused by problems related to weight loss focuses on insulin and insulin-sensitizing medication that can help induce fertility without the use of fertility drugs
- A treatment option for women over 35 who do not wish to maintain fertility may include removing the ovaries (oophorectomy).The uterus removal (hysterectomy) may be recommended too if there are symptoms such as abnormal bleeding. Depending on medical history, hysterectomy may not be recommended because of consecutive surgery risks and complications
- Treatment for obesity focuses on diet, exercise and weight loss
- Treatment for weight loss may decrease the risk for heart disease and diabetes
- Treatment for elevated androgen levels and hirsutism may include the use of antiandrogens such as spironolactone.
Excess hair growth may require medication or physical removal.


Prophylaxis

Polycystic ovary syndrome can be prevented. However, if there is a family history of this syndrome, diagnosis and early treatment can help relieve symptoms and decreased risk of developing complications such as diabetes or heart disease.

Overview

Home treatment

Home treatment measures can help control the symptoms of PCOS and the fulfillment of a healthy life. Measures such as weight control can reduce the risk for diabetes, hypertension and high cholesterol.
Weight control or weight loss may result in resumption of ovulatory cycles and fertility. Weight loss, even if only 5-7% within 6 months may reduce testosterone levels and return of ovulation and fertility in more than 75% of women with PCOS.
- Maintaining a healthy weight. A healthy weight maintain a good feeling about themselves, energy for work and leisure time and control PCOS symptoms
- Weight loss. Achieving a healthy weight improves health and prevents long-term complications. Age, metabolism, genetics and the amount of movement, play an important role in growth or weight loss
- Exercise. Physical activity must become an essential activity every day. There are several ways of doing exercise, walking is one of the best. We recommend choosing the right exercise for each individual, to motivate them
- Balanced diet. This type of diet that includes fruits and vegetables, whole grains and dairy products low in fat, cover the body’s nutritional needs, satisfies hunger, decreases appetite and reduces the risk for other medical conditions such as cancer or osteoporosis. With this diet, the person generally feels better and has more energy.

Acne treatment may include topical medications (topical) or oral medication, which may be prescribed by a doctor or not. Some women find a good evolution of the acne after hormonal treatment.
Excess hair (hirsutism) may be removed by:
- Laser hair removal, which destroys the hair follicle
- Electrolysis, the hair is permanently removed by electric current applied to the root
- Depilatory creams, applying them to cause a chemical hair removal
- Wax, with which to pluck hair from the root
- Shaving
- Discoloration
Hair removal methods differ in cost and in long term efficiency. Some methods have a higher risk of infection of the skin and the appearance of scars. Drugs or creams may be recommended.

Overview

Medications
Medical treatment of PCOS focuses on the regulation of ovulation, the treatment of insulin resistance or both. Medical treatment depends on patient symptoms and desire to become pregnant. May be prescribed medication to treat symptoms such as acne or excess hair growth.

The choice of drug treatment

Medications to treat reproductive or metabolic problems of PCOS may include:
- Combination of estrogen and progesterone, such as birth control pills, vaginal ring or skin patch. Estrogen may help to lower levels of male hormones, thus reducing problems of acne and excess hair
- Clomiphene citrate (fertility medication) or injections of gonadotropins (LH, luteinizing hormone and follicle stimulating hormone FSH)
- Metformin. This medication may reduce metabolic disorders and levels of male hormones of PCOS, helping the occurrence of regular menstrual cycles. The efficiency of this treatment can increase the weight loss
- Medications that suppress the male hormones (anti-androgens), such as spironolactone
- Synthetic progestin like medroxyprogesterone acetate.

Can be recommended medication to treat excess hair (hirsutism), such as spironolactone. The use of spironolactone is outside the recommendations of the leaflet.
Some medications to treat hirsutism may increase the risk for metabolic problems, so it is important to discuss side effects with your doctor.
Acne treatment may include topical medications (topical) or oral medication, which may be prescribed by a doctor or not. Some women find a good evolution of the acne after hormonal treatment.

Remember!

Treatment focuses on removing PCOS symptoms and prevent long term complications. There is no specific treatment to cure the disease, but most women live a healthy life with medical outpatients.
Women with PCOS who become pregnant may have a higher risk of developing gestational diabetes during pregnancy.


Surgical treatment

Surgery for PCOS may include:
- Removing part of the ovary to stimulate fertility, if she wants to get pregnant
- Remove the ovaries if she does not want to get pregnant.

Types of surgery

- Laparoscopic ovarian surgery is a surgical treatment that can trigger ovulation in women with PCOS who have failed at weight loss and fertility medication. Electrocautery or laser are used to destroy portions of ovaries
- Bilateral salpingo-oophorectomy and hysterectomy is the surgical removal of the uterus, fallopian tubes and ovaries

Remember!

Treatment focuses on removing PCOS symptoms and prevent long term complications. There is no specific treatment to cure the disease. Surgery for PCOS may be recommended if the patient has not responded to other treatments.
Hysterectomy, with or without bilateral salpingo-oophorectomy may be an option and may eliminate abnormal vaginal bleeding, polycystic ovary syndrome symptoms and reduce the risk of cancer. However, the causes of this syndrome are also related to hormonal and metabolic problems that can not be solved by removing the reproductive organs. Depending on medical history, hysterectomy for PCOS can not be recommended because of possible risks and complications of surgery.

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