The primary clinical features that may be the first indication of polycystic ovary syndrome (PCOS) includes :
- Oligomenorrhea – infrequent irregular periods, often heavy when it does occur although it may be scanty (very light).
- Amenorrhea – the complete absence or cessation of periods for 3 or more months.
Many females also seek medical attention for the other signs and symptoms of PCOS, which includes :
- Dysmenorrhea – painful periods
- Infertility – difficulty or the inability to fall pregnant
- Hirsutism – abnormal growth of hair on the face, chest or back
Criteria for PCOS Diagnosis
At least 2 of the 3 criteria (menstrual disturbances, ovarian features and/or androgen excess) below should be present in order to diagnose polycystic ovary syndrome. In addition, other conditions need to be excluded, including pregnancy, hypothyroidism, Cushing’s syndrome, tumors (ovary, uterus), and the use of certain drugs that are known to cause these clinical features. It is important to note that the presence of cysts or infertility is not present in every case of PCOS.
- Oligomenorrhea or amenorrhea which may indicate oligo-ovulation (infrequent) or anovulation (no ovulation).
Ovarian Features (ultrasound)
- 12 or more follicles (cysts) in at least one ovary measuring 2 or more millimeters in diameter OR
- Enlargement of the ovary resulting in a total ovarian volume > 10 cm3.
- Hyperandrogenism refers to signs of excessive androgens (male hormones) in females, which may include hirsutism, acne, androgenic alopecia (male-pattern baldness). The development of actual secondary male sexual characteristics is known as virilism and is rare in women with PCOS. OR
- Hyperandrogenemiarefers to blood tests that indicate an excess of androgens (male hormones) in females. This includes :
- Free testosterone – elevated
- Dehydroepiandrosterone-sulfate (DHEA-S) – normal or slightly above normal
- Sex hormone–binding globulin (SHBG) – low
- Other biochemical investigations are discussed under PCOS Blood Tests.
Treatment of PCOS
Treatment of poylcystic ovarian/ovary syndrome (PCOS) depends on the clinical features present and whether pregnancy is desired. Diet and exercise are essential components of PCOS treatment and management, especially in obese patients and those with diabetes mellitus.
The aim of treatment is to :
Regulate the menstrual cycle
Decrease body weight
Prevent and manage complications associated with PCOS
Treatment also helps to reduce the severity and extent of other PCOS symptoms and clinical features such as hirsutism.
Metformin is an antidiabetic medication which is used for insulin resistance and reducing the blood glucose levels. It improves glucose tolerance and assists with reducing the elevated blood insulin levels (hyperinsulinemia). Metformin also helps with improving the ovulation rate in many cases of PCOS, especially when used with clomiphene citrate. Patients on metformin may also find moderate weight loss, which is helpful in women who are overweight or obese, but it should not be solely used for weight management. Thiazolidinediones are another type of diabetes medication that may be used but it is not suitable if pregnancy is desired.
Oral contraceptives (combination – estrogen + progesterone) may help with regulating the menstrual cycle by the secretion of LH (luteinizing hormone) and FSH (follicle-stimulating hormone). This decreases androgen production by the ovaries. It is used in women with PCOS who do not wish to fall pregnant. Oral contraceptives may be used for periods of time before being discontinued in an attempt to stabilize the cycle.
Clomiphene citrate stimulates ovulation by decreasing the negative feedback mechanism of estrogen on FSH (follicle stimulating hormone). It is widely used for the treatment of infertility as a result of anovulation. Concurrent use of metformin may significantly increase ovulatory cycles thereby increasing the chances of pregnancy.
Other medication for the treatment of hypertension and hyperlipidemia may be considered if these conditions are present in a woman with PCOS.
There are two surgical procedures used in the treatment of polycystic ovarian syndrome. Surgery is considered when medical treatment (medication) fails to achieve the desired results. Abnormally large cysts may prompt surgery sooner.
The preferred method is laparoscopic surgery, also known as laparoscopic ovarian drilling. Various methods, including electrocautery, laser drilling or multiple biopsy, are used to create focal areas of damage on the thickened ovarian capsule.
The other surgical method which is not as widely used these days is ovarian wedge resection. Here a portion of the ovarian tissue is removed and the ovary sutured. The chances of complications like hemorrhage and adhesions are greater than with laparoscopic drilling. A less common complication is ovarian atrophy.
Dietary changes and exercise should not be discontinued after surgery.