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Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS)

Topic Overview

What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome (say "pah-lee-SIS-tik OH-vuh-ree SIN-drohm") is a problem in which a woman's hormones are out of balance. It can cause problems with your periods and make it difficult to get pregnant. PCOS also may cause unwanted changes in the way you look. If it isn't treated, over time it can lead to serious health problems, such as diabetes and heart disease.

Most women with PCOS grow many small cysts on their ovaries. That is why it is called polycystic ovary syndrome. The cysts are not harmful but lead to hormone imbalances.

Early diagnosis and treatment can help control the symptoms and prevent long-term problems.

What are hormones, and what happens in PCOS?

Hormones are chemical messengers that trigger many different processes, including growth and energy production. Often, the job of one hormone is to signal the release of another hormone.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change triggers another, which changes another. For example:

  • The sex hormones get out of balance. Normally, the ovaries make a tiny amount of male sex hormones (androgens). In PCOS, they start making slightly more androgens. This may cause you to stop ovulating, get acne, and grow extra facial and body hair.
  • The body may have a problem using insulin, called insulin resistance. When the body doesn't use insulin well, blood sugar levels go up. Over time, this increases your chance of getting diabetes.

What causes PCOS?

The cause of PCOS is not fully understood, but genetics may be a factor. PCOS seems to run in families, so your chance of having it is higher if other women in your family have it or have irregular periods or diabetes. PCOS can be passed down from either your mother's or father's side.

What are the symptoms?

Symptoms tend to be mild at first. You may have only a few symptoms or a lot of them. The most common symptoms are:

  • Acne.
  • Weight gain and trouble losing weight.
  • Extra hair on the face and body. Often women get thicker and darker facial hair and more hair on the chest, belly, and back.
  • Thinning hair on the scalp.
  • Irregular periods. Often women with PCOS have fewer than nine periods a year. Some women have no periods. Others have very heavy bleeding.
  • Fertility problems. Many women who have PCOS have trouble getting pregnant (infertility).
  • Depression.

How is PCOS diagnosed?

To diagnose PCOS, the doctor will:

  • Ask questions about your past health, symptoms, and menstrual cycles.
  • Do a physical exam to look for signs of PCOS, such as extra body hair and high blood pressure. The doctor will also check your height and weight to see if you have a healthy body mass index (BMI).
  • Do a number of lab tests to check your blood sugar, insulin, and other hormone levels. Hormone tests can help rule out thyroid or other gland problems that could cause similar symptoms.

You may also have a pelvic ultrasound to look for cysts on your ovaries. Your doctor may be able to tell you that you have PCOS without an ultrasound, but this test will help him or her rule out other problems.

How is it treated?

Regular exercise, healthy foods, and weight control are the key treatments for PCOS. Treatment can reduce unpleasant symptoms and help prevent long-term health problems.

  • Try to fit in moderate activity and/or vigorous activity often. Walking is a great exercise that most people can do.
  • Eat heart-healthy foods. This includes lots of vegetables, fruits, nuts, beans, and whole grains. It limits foods that are high in saturated fat, such as meats, cheeses, and fried foods.
  • Most women who have PCOS can benefit from losing weight. Even losing 10 lb (4.5 kg) may help get your hormones in balance and regulate your menstrual cycle.
  • If you smoke, consider quitting. Women who smoke have higher androgen levels that may contribute to PCOS symptoms.footnote 1

Your doctor also may prescribe birth control pills to reduce symptoms, metformin to help you have regular menstrual cycles, or fertility medicines if you are having trouble getting pregnant.

It is important to see your doctor for follow-up to make sure that treatment is working and to adjust it if needed. You may also need regular tests to check for diabetes, high blood pressure, and other possible problems.

It may take a while for treatments to help with symptoms such as facial hair or acne. You can use over-the-counter or prescription medicines for acne.

It can be hard to deal with having PCOS. If you are feeling sad or depressed, it may help to talk to a counselor or to other women who have PCOS.

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Cause

The cause of polycystic ovary syndrome (PCOS) is not fully understood, but genetics may be a factor.

PCOS problems are caused by hormone changes. One hormone change triggers another, which changes another.

Symptoms

Symptoms of polycystic ovary syndrome (PCOS) tend to start gradually. Hormone changes that lead to PCOS often start in the early teens, after the first menstrual period. Symptoms may be especially noticeable after a weight gain.

Symptoms may include:

  • Menstrual problems. These can include few or no menstrual periods or heavy, irregular bleeding.
  • Hair loss from the scalp and hair growth (hirsutism) on the face, chest, back, stomach, thumbs, or toes.
  • Acne and oily skin
  • Fertility problems, such as not releasing an egg (not ovulating) or repeat miscarriages.
  • Insulin resistance and too much insulin (hyperinsulinemia), which can cause things like upper body obesity and skin tags.
  • Depression or mood swings. For more information, see the topic Depression or Depression in Children and Teens.
  • Breathing problems while sleeping (obstructive sleep apnea). This is linked to both obesity and insulin resistance.

What Happens

Polycystic ovary syndrome (PCOS) can affect your reproductive system and how your body handles blood sugar. It can also affect your heart.

Reproductive problems

Hormone imbalances can cause several types of pregnancy problems and related problems, including:

  • Infertility. This happens when the ovaries aren't releasing an egg every month.
  • Repeat miscarriages.
  • Gestational diabetes during pregnancy.
  • Increased blood pressure during pregnancy or delivery, having a larger than normal or smaller than normal baby, or having a premature baby.
  • Precancer of the uterine lining (endometrial hyperplasia). This can happen when you don't have regular menstrual cycles, which normally build up and "clear off" the uterine lining every month.
  • Uterine (endometrial) cancer. Risk during the reproductive years is 3 times greater in women who have PCOS than in women who ovulate monthly.footnote 2

Problems with blood sugar

Insulin is a hormone that helps your body's cells get the sugar they need for energy. Sometimes these cells don't fully respond to insulin. This is called insulin resistance. It can lead to diabetes.

Heart problems and stroke

High insulin levels from PCOS can lead to heart and blood vessel problems. These include:

  • Hardening of the arteries (atherosclerosis).
  • Coronary artery disease and heart attack.
  • High blood pressure.
  • High cholesterol.
  • Stroke.

What Increases Your Risk

The main risk factor for polycystic ovary syndrome (PCOS) is a family history of it. Your chance of having it is higher if other women in your family have it or have irregular periods or diabetes. PCOS can be passed down from either your mother's or father's side.

A family history of diabetes may increase your risk for PCOS because of the strong relationship between diabetes and PCOS.

Long-term use of the seizure medicine valproate (such as Depakote) has been linked to an increased risk of PCOS.footnote 1

When should you call your doctor?

Polycystic ovary syndrome (PCOS) causes a wide range of symptoms, so it may be hard to know when to see your doctor. But early diagnosis and treatment will help prevent serious health problems, such as diabetes and heart disease. See your doctor if you have symptoms that suggest PCOS.

Call your doctor now or seek immediate medical care if:

  • You have severe vaginal bleeding. You are soaking through your usual pads or tampons every hour for 2 or more hours.

Call your doctor if you have:

  • Skipped your period for 3 months or more.
  • More vaginal bleeding than usual, or bleeding is more irregular.
  • Regular menstrual cycles but you have been trying unsuccessfully to become pregnant for more than 12 months.
  • Any symptoms of diabetes, such as increased thirst and frequent urination (especially at night), unexplained increase in appetite, unexplained weight loss, fatigue, blurred vision, or tingling or numbness in your hands or feet.
  • Depression or mood swings.

Watchful waiting

Taking a wait-and-see approach (called watchful waiting) is not a good choice if you may have PCOS. Early diagnosis and treatment may help prevent future problems.

Exams and Tests

No single test can show that you have polycystic ovary syndrome (PCOS). Your doctor will talk to you about your medical history, do a physical exam, and run some tests.

Medical history

The medical history includes questions about your symptoms. Your doctor may ask you about changes in your weight, skin, hair, and menstrual cycle. He or she may also ask you about problems with getting pregnant, medicines you are taking, and your eating and exercise habits.

You will also talk about any family history of hormone problems, including diabetes.

Physical exam

The physical exam checks your thyroid gland, skin, hair, breasts, and belly. You will have a blood pressure check and a pelvic exam to find out if you have enlarged or abnormal ovaries. Your doctor can also check your body mass index (BMI).

Ultrasound

You may have a pelvic ultrasound, which might show enlarged ovaries with small cysts. These are signs of PCOS. But many women with PCOS don't have these signs.

Lab tests

You may have blood tests to check for:

Testing for problems from PCOS

Diabetes. If you have PCOS, experts recommend that you have blood glucose testing for diabetes by age 30. footnote 3You may have this done at a younger age if you have PCOS and other risk factors for diabetes (such as obesity, lack of exercise, a family history of diabetes, or gestational diabetes during a past pregnancy). After this, your doctor will tell you how often to have testing for diabetes.

Heart disease. Your doctor will regularly check your cholesterol and triglycerides, blood pressure, and weight. This is because PCOS is linked to higher risks of high blood pressure, weight gain, high cholesterol, heart disease, hardening of the arteries (atherosclerosis), heart attack, and stroke.

Uterine (endometrial) cancer. Regular menstrual cycles normally build up and "clear off" the uterine lining every month. When the uterine lining builds up for a long time, precancer of the uterine lining (endometrial hyperplasia) can grow. If you have had infrequent menstrual periods for at least 1 year, your doctor may use a transvaginal ultrasound and/or endometrial biopsy to look for signs of precancer or cancer.footnote 4

Treatment Overview

Regular exercise, a healthy diet, weight control, and not smoking are all important parts of treatment for polycystic ovary syndrome (PCOS). You may also take medicine to balance your hormones.

Treatments depend on your symptoms and whether you are planning a pregnancy.

There is no cure for PCOS, but controlling it lowers your risks of infertility, miscarriages, diabetes, heart disease, and uterine cancer.

Healthy lifestyle

  • If you are overweight, weight loss may be all the treatment you need. A small amount of weight loss is likely to help balance your hormones and start up your menstrual cycle and ovulation.
  • Eat a balanced diet that includes lots of fruits, vegetables, whole grains, and low-fat dairy products.
  • Get regular exercise to help you control or lose weight and feel better.
  • If you smoke, consider quitting. Women who smoke have higher levels of androgens than women who don't smoke.footnote 1

For more information, see Home Treatment.

Hormone therapy

If weight loss alone doesn't start ovulation (or if you don't need to lose weight), your doctor may have you try a medicine such as metformin or clomiphene to help you start to ovulate.

If you aren't planning a pregnancy, you can also use hormone therapy to help control your ovary hormones. To correct menstrual cycle problems, birth control hormones keep your endometrial lining from building up for too long. This can prevent uterine cancer.

Hormone therapy also can help with male-type hair growth and acne. Birth control pills, patches, or vaginal rings are prescribed for hormone therapy. Androgen-lowering spironolactone (Aldactone) is often used with combined hormonal birth control. This helps with hair loss, acne, and male-pattern hair growth on the face and body (hirsutism).

You can use other methods to treat acne and remove excess hair. For more information, see Home Treatment.

Taking hormones doesn't help with heart, blood pressure, cholesterol, and diabetes risks. This is why exercise and a healthy diet are key parts of your treatment.

To learn more about hormones, see Medications.

If weight loss and medicine don't restart ovulation, you may want to try other treatments. For more information, see the topic Fertility Problems.

Regular checkups

Regular checkups are important for catching any PCOS complications, such as high blood pressure, high cholesterol, uterine cancer, heart disease, and diabetes.

Prevention

Polycystic ovary syndrome (PCOS) cannot be prevented. But early diagnosis and treatment helps prevent long-term complications, such as infertility, metabolic syndrome, obesity, diabetes, and heart disease.

Home Treatment

Home treatment can help you manage the symptoms of polycystic ovary syndrome (PCOS) and live a healthy life.

Healthy eating and exercise

Eat a balanced diet. A diet that includes lots of fruits, vegetables, whole grains, and low-fat dairy products supplies your body's nutritional needs, satisfies your hunger, and decreases your cravings. And a healthy diet makes you feel better and have more energy.

You may see a registered dietitian who has special knowledge about diabetes.

For more information, see the topic Healthy Eating.

Make physical activity a regular and essential part of your life. Choose fitness activities that are right for you to help boost your motivation. Walking is one of the best activities. Having a walking or exercise partner that you can count on can also be a great way to stay active. For more information, see the topic Fitness.

Weight control and weight loss

Stay at a healthy weight. This is the weight at which you feel good about yourself, have energy for work and play, and can manage your PCOS symptoms.

If you need to lose weight, doing so will lower your risks for diabetes, high blood pressure (hypertension), and high cholesterol.footnote 5

A modest weight loss can improve high androgen and high insulin levels and infertility. Weight loss of as little as 5% to 7% over 6 months can reduce androgen levels enough to restore ovulation and fertility in more than 75% of women who have PCOS.footnote 6

Losing weight can be hard, but you can do it. The easiest way to start is by cutting calories and becoming more active. For help, see the topic Weight Management.

Don't smoke

If you smoke, consider quitting. Women who smoke have higher levels of androgens than women who don't smoke. footnote 7Smoking also increases the risk for heart disease. For more information, see Quitting Smoking.

Caring for skin and hair

Acne treatment may include nonprescription or prescription medicines that you put on your skin (topical) or take by mouth (oral). Some women notice an improvement in their acne after using estrogen-progestin hormone pills. For more information, see the topic Acne.

Excess hair growth (hirsutism) slows when high androgen levels decrease. In the meantime, you can remove or treat unwanted hair with:

  • Laser hair removal, in which the hair follicle is destroyed by a laser beam.
  • Electrolysis, in which your hair is permanently removed by electric current applied to the hair root.
  • Depilatories, which are chemical hair removal products applied to the skin.
  • Waxing, which pulls the hair out by the root.
  • Shaving.
  • Tweezing.
  • Bleaching.

Hair removal methods differ in cost and long-term effectiveness. Before trying one, ask your doctor about risks of infection and scarring.

Medications

As part of polycystic ovary syndrome (PCOS) treatment, medicines can be used to help control reproductive hormone or insulin levels.

Medicine choices

Medicines to treat reproductive or metabolic problems include:

  • Combination estrogen and progestin hormones in birth control pills, vaginal rings, or skin patches. These hormones correct irregular menstrual bleeding or absent menstrual cycles. They may also improve your androgen-related acne problems, male-type hair growth, and male-pattern hair loss.
  • Synthetic progestin. If you are not able to use the hormone estrogen, talk to your doctor about using progestin shots or pills for part of your cycle. The progestin makes your endometrial lining build up and shed, similar to a menstrual period. This monthly shedding is what prevents uterine cancer.
  • Androgen-lowering spironolactone (Aldactone), which is a diuretic. It is often used with estrogen-progestin therapy. This reduces hair loss, acne, and abnormal hair growth on the face and body (hirsutism).
  • Metformin (Glucophage). This diabetes medicine is used for controlling insulin, blood sugar levels, and androgen levels.
  • Clomiphene (Clomid), letrozole (Femara), and gonadotropin injections (LH and FSH) can trigger ovulation.

Eflornithine (such as Vaniqa) is a prescription skin cream that slows hair growth for as long as you use it regularly. Talk to your doctor about whether it is right for you.

Treatment for acne includes nonprescription and prescription medicines that are applied to the skin (topical) or taken by mouth (oral). For more information, see Acne.

Combination hormone pills may improve acne that is related to high androgen levels.footnote 8

Surgery

Surgical treatment is sometimes used for women with infertility caused by polycystic ovary syndrome (PCOS) who do not start ovulating after taking medicine.

Surgery choices

Laparoscopic ovarian drilling is a surgical treatment that can trigger ovulation in women who have PCOS and who have not responded to weight loss and fertility medicine. Electrocautery or a laser is used to destroy portions of the ovaries.

What to think about

Surgery for PCOS may be recommended only if you have not responded to any other treatment for PCOS. Each woman will want to discuss the risks and benefits of this surgery with her doctor. Surgery is less likely to lead to multiple pregnancies than taking fertility medicines. It is not known how long the benefits from surgery will last. There is some concern that ovarian surgery can cause scar tissue, which can lead to pain or more fertility problems.

References

Citations

  1. Keefe K, Pal L (2014). Polycystic ovary syndrome. In EG Nabel et al., eds., Scientific American Medicine, chap. 66. Hamilton, ON: BC Decker. https://www.deckerip.com/decker/scientific-american-medicine/chapter/66. Accessed date April 13, 2017.
  2. Fritz MA, Speroff L (2011). Chronic anovulation and the polycystic ovary syndrome. Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 495–531. Lippincott Williams and Wilkins.
  3. American Association of Clinical Endocrinologists (2005). Position statement on metabolic and cardiovascular consequences of polycystic ovary syndrome. Endocrine Practice: 11(2): 126–134.
  4. Ehrmann DA (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12): 1223–1236.
  5. Fritz MA, Speroff L (2011). Chronic anovulation and the polycystic ovary syndrome. Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 495–531. Lippincott Williams and Wilkins.
  6. Huang I, et al. (2007). Endocrine disorders. In JS Berek, ed., Berek and Novak's Gynecology, 14th ed., pp. 1069–1135. Philadelphia: Lippincott Williams and Wilkins.
  7. Keefe K, Pal L (2014). Polycystic ovary syndrome. In EG Nabel et al., eds., Scientific American Medicine, chap. 66. Hamilton, ON: BC Decker. https://www.deckerip.com/decker/scientific-american-medicine/chapter/66. Accessed date April 13, 2017.
  8. Ehrmann DA (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12): 1223–1236.

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2009). Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. Obstetrics and Gynecology, 114(4): 936–949.
  • Cahill DJ, O'Brien K (2015). Polycystic ovary syndrome (PCOS): Metformin. BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/1408/overview.html. Accessed September 22, 2015.
  • Dronavalli S, Ehrmann DA (2007). Pharmacologic therapy of polycystic ovary syndrome. Clinical Obstetrics and Gynecology, 50(1): 244–254.
  • Hall J (2007). Neuroendocrine changes with reproductive aging in women. Seminars in Reproductive Medicine, 25(5): 344–351.
  • Polycystic Ovary Syndrome Writing Committee (2005). American Association of Clinical Endocrinologists position statement on metabolic and cardiovascular consequences of polycystic ovary syndrome. Endocrine Practice, 11(2): 125–134.
  • Practice Committee of the American Society for Reproductive Medicine (2006). The evaluation and treatment of androgen excess. Fertility and Sterility, 86(4, Suppl): S241–S247.
  • Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group (2003). Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertility and Sterility, 81(1): 19–25.
  • Setji T, Brown AJ (2007). Polycystic ovary syndrome: Diagnosis and treatment. American Journal of Medicine, 120(2): 128–132.
  • Thatcher SS, Jackson EM (2006). Pregnancy outcome in infertile patients with polycystic ovary syndrome who were treated with metformin. Fertility and Sterility, 85(4): 1002–1009.

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