Polycystic ovary syndrome is characterized by irregular or no menstrual periods and often obesity or symptoms caused by high levels of male hormones (androgens), such as excess body hair and acne.
Typically, women have irregular or no periods, and often, they are overweight or obese and develop acne and characteristics caused by male hormones such as excess body hair).
Doctors often base the diagnosis on symptoms, but blood tests to measure hormone levels and ultrasonography may also be done.
Exercise, weight loss and/or medications with estrogen plus a progestin may help reduce symptoms (including excess body hair) and restore hormone levels to normal.
Polycystic ovary syndrome affects about 5 to 10% of women.
In the United States, it is the most common cause of infertility.
This syndrome gets its name from the many fluid-filled sacs (cysts) that often develop in the ovaries, causing them to enlarge.
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In many women with polycystic ovary syndrome, the body’s cells resist the effects of insulin (called insulin resistance or sometimes prediabetes). Insulin helps sugar (glucose) pass into cells so that they can use it for energy. When cells resist its effects, sugar accumulates in the blood, and the pancreas produces more insulin to try to lower sugar levels in the blood. If insulin resistance becomes moderate or severe, diabetes may develop.
If women who have polycystic ovary syndrome and are overweight or obese become pregnant, their risk of complications during pregnancy is increased. These complications include gestational diabetes (diabetes that develops during pregnancy), preterm delivery, and preeclampsia (a type of high blood pressure that develops during pregnancy).
Causes of Polycystic Ovary Syndrome
What causes polycystic ovary syndrome is not clear. Some evidence suggests that it is caused by malfunction of the enzyme controlling the production of male hormones. This malfunction causes the production of male hormones (androgens) to increase.
High levels of male hormones increase the risk of metabolic syndrome (with high blood pressure, high cholesterol levels, and resistance to the effects of insulin) and risk of obesity. If male hormone levels remain high, the risk of diabetes, heart and blood vessel disorders (including atherosclerosis and coronary artery disease), and high blood pressure is increased. Also, some of the male hormones may be converted to estrogen, increasing estrogen levels. If not enough progesterone is produced to balance the increased level of estrogen and this situation continues a long time, the lining of the uterus (endometrium) may become extremely thick (a condition called endometrial hyperplasia) or cancer of the lining of the uterus (endometrial cancer) may develop. Polycystic ovary syndrome may also increase the risk of nonalcoholic fatty liver disease (abnormal accumulation of fats inside liver cells that is not related to alcohol consumption).
Symptoms of Polycystic Ovary Syndrome
Symptoms of polycystic ovary syndrome typically develop during puberty and worsen with time. Symptoms vary from woman to woman.
Sometimes in girls with polycystic ovary syndrome, menstrual periods do not start at puberty, and the ovaries do not release an egg (that is, women do not ovulate) or release an egg irregularly. Women or girls who have already started menstruation may have irregular vaginal bleeding or menstrual periods may stop.
Women may also develop symptoms related to the high levels of male hormones—called masculinization or virilization. Common symptoms include acne and an increase in body hair (hirsutism). Rarely, changes include a deepened voice, a decrease in breast size, an increase in muscle size, hair growth in a male pattern (for example, on the chest and face), and thinning of hair or baldness.
Many women with polycystic ovary syndrome have excess body weight, but some are thin. Producing too much insulin contributes to weight gain and makes losing weight difficult. Excess insulin due to insulin resistance may also cause skin in the armpits, on the nape of the neck, and in skinfolds to become dark and thick (a disorder called acanthosis nigricans).
Other symptoms may include fatigue, low energy, sleep-related problems (including sleep apnea), mood swings, depression, anxiety, and headaches.
If women develop metabolic syndrome, fat may accumulate in the abdomen.
Diagnosis of Polycystic Ovary Syndrome
A doctor's evaluation, based on specific diagnostic criteria
Ultrasonography
Measurement of hormone levels
Often, the diagnosis of polycystic ovary syndrome is based on symptoms.
A pregnancy test is usually done. Blood tests to measure levels of male hormones are done and possibly levels of other hormones to check for other conditions, such as premature menopause or, rarely, Cushing syndrome.
Ultrasonography is done to see whether the ovaries contain many cysts and to check for a tumor in an ovary or adrenal gland. These tumors can produce excess male hormones and thus cause the same symptoms as polycystic ovary syndrome. Ultrasonography may be done to check for abnormalities in the ovaries. Transvaginal ultrasonography is done if possible. It involves using a small handheld device inserted through the vagina to view the interior of the uterus. Transvaginal ultrasonography is not usually used in adolescent girls because the changes of puberty make it less likely to help diagnose polycystic ovary syndrome.
Often, a biopsy of the uterine lining (endometrial biopsy) is done to make sure no cancer is present, particularly if women have abnormal vaginal bleeding.
In women with this syndrome, doctors may do other tests to check for complications or other conditions that often occur in women with polycystic ovarian syndrome. Doctors may measure blood pressure and usually levels of blood sugar and fats (lipids), such as cholesterol, to check for metabolic syndrome, which increases the risk of coronary artery disease.
Doctors may also do imaging tests to check for evidence of coronary artery disease. Imaging tests include coronary angiography (x-rays of arteries taken after a radiopaque contrast agent, which can be seen on x-rays, is injected into an artery) and computed tomography (CT) angiography (2- and 3-dimensional images of blood vessels taken after a radiopaque contrast agent is injected into a vein).
Because women with polycystic ovary syndrome may have depression and anxiety, doctors ask them about symptoms of these disorders. If a problem is identified, they are referred to a mental health care practitioner and/or treated as needed.
Treatment of Polycystic Ovary Syndrome
Exercise, dietary changes, and sometimes weight loss
Management of excess body hair and acne
Management of long-term risks of hormone abnormalities
Infertility treatments if women want to become pregnant
The choice of treatment for polycystic ovary syndrome depends on the following:
Type and severity of symptoms
The woman’s age
Her plans regarding pregnancy
General measures
If insulin levels are high, lowering them may help. Exercising (at least 30 minutes a day) and reducing consumption of carbohydrates (in breads, pasta, potatoes, and sweets) can help lower insulin levels.
If women have excess body weight (overweight or obesity), weight loss may help with the following:
Lowering insulin levels enough that ovulation can begin
Increasing the chances of becoming pregnant
Making menstrual periods more regular
Reducing hair growth and the risk of thickening of the uterine lining
Weight loss (bariatric) surgery may help some women. Weight loss is unlikely to benefit normal-weight women with polycystic ovary syndrome.
Medications
Women who do not wish to become pregnant are usually given a birth control pill that contains estrogen and a progestin (a combination oral contraceptive) or only a progestin (a synthetic form of the female hormone progesterone), such as that released by an intrauterine device
Reduce the risk of endometrial cancer due to the high estrogen level
Make menstrual periods more regular
Help lower the levels of male hormones
Slightly reduce excess body hair and acne
insulin so the body does not have to make as much insulin
insulin act more effectively) may reduce symptoms related to the high levels of male hormones (such as excess body hair) and lessen insulin resistance.
fertility druginsulininsulin levels may trigger ovulation. If none of these medications is effective, other fertility treatments may be tried. They include follicle-stimulating hormone (to stimulate the ovaries), a gonadotropin-releasing hormone (GnRH) agonists (to stimulate the release of follicle-stimulating hormone), and human chorionic gonadotropin (to trigger ovulation).
If fertility medications are ineffective or if women do not wish to take them, surgery (such as ovarian drilling) may be tried. It is done by laparoscopy. Doctors make smalls incisions just above or below the navel. They then insert a thin viewing tube (called a laparoscope) into the abdominal cavity through one incision. Through another incision, they insert special tools that use an electric current or laser to destroy small areas of the ovaries that produce male hormones (androgens). Thus, androgen production is decreased. Decreasing the high levels of androgens in women with polycystic ovary syndrome can help regulate menstrual cycles and improve the chances of pregnancy. General anesthesia is required.
Treatment of excess body hair
Treatment of excess body hair includes bleaching or removal by electrolysis, plucking, waxing, hair-removing liquids or creams (depilatories), or laser. No treatments for removing excess hair is ideal or completely effective. The following may help:
may help remove unwanted facial hair.
Birth control pills may help, but they must be taken for several months before any effect, which is often slight, can be seen.
Cyproterone, a strong progestin that blocks the action of male hormones, reduces the amount of unwanted body hair in 50 to 75% of affected women. It is used in many countries but is not approved in the United States.
Gonadotropin-releasing hormone agonists and antagonists are being studied as treatment for unwanted body hair. Both types of medications inhibit the production of sex hormones by the ovaries. But both can cause bone loss and lead to osteoporosis.
Losing weight reduces production of androgens and thus may slow hair growth.
