Polycystic Ovarian Syndrome
by Jenny Ashmore
Polycystic ovarian syndrome, or PCOS, is an endocrine disorder in which a female has too much of the hormone testosterone. It occurs in up to eight percent of females worldwide, making it the most common endocrine disorder in females (Lujan, M. E., Chizen, D. R., & Pierson, R. A., 2008). As it is becoming more and more prevalent, awareness of the condition is becoming more widespread, but there is still a lot of research to be done on polycystic ovarian syndrome.
It is known by most that the two main sex hormones within the human body are estrogen and testosterone. Estrogen is known as the female sex hormone because it produces feminine sexual characteristics, and testosterone is known as the male sex hormone because it produces more masculine sexual characteristics. However, both males and females need both of these hormones- in different ratios, of course. Men need more testosterone and less estrogen, and women need the opposite. Any imbalances in the specific ratios that a male or female needs can cause health problems- one of these problems being polycystic ovarian syndrome.
In an adult female with the ideal hormonal balance, serum estrogen levels should be 15-350 pg/mL (Mayo Medical Laboratories, n.d.). Total testosterone (unbound/unavailable combined with bound testosterone) for a woman over the age of 19 should be 8-60 ng/dL (Mayo Medical Laboratories, n.d., second source). Bioavailable testosterone, that is unbound and can bind to tissues, should be 0.8-10 ng/dL in a woman aged 20-50 who is not on oral contraceptives (Mayo Medical Laboratories, n.d., second source). This all comes into play in the diagnosis of polycystic ovarian syndrome.
The Rotterdam Criteria is the most commonly used diagnostic criteria by medical professionals today. It was created in 2003 by the European Society for Human Reproduction and embryology and the American Society for reproductive medicine. It is a set of 3 criteria that characterizes features of polycystic ovarian syndrome, and in order to receive a diagnosis, the patient has to meet at least two out of the three of the criteria. The first of the three criteria is the patient must have oligo- or chronic anovulation. Anovulation is when a woman does not ovulate when she is supposed to every month, and is usually characterized by a missed menstrual period as well. Oligo- or chronic anovulation means that the patient does not ever ovulate or only ovulated nine or less months out of the year. The second of the Rotterdam Criteria is presence of clinical signs of hyperandrogenism (excess testosterone) and/or biochemical evidence of hyperandrogenism (ie. high total/bioavailable testosterone) (Lujan, M. E., Chizen, D. R., & Pierson, R. A., 2008). The clinical signs of hyperandrogenism include hirsutism (inappropriate hair growth), alopecia, obesity, hidradenitis suppurativa (an inflammatory condition of the apocrine glands), oligomenorrhea, severe insulin resistance, acne, infertility, type two diabetes, and decreased libido (Karnath, MD, B. M., 2008).
The third of the three Rotterdam Criteria used for the diagnosis of polycystic ovarian syndrome is the presence of polycystic ovaries, which can be seen using a pelvic ultrasound device (3). Lastly, before diagnosing a patient with PCOS based on these Rotterdam Criteria, the healthcare practitioner must rule out all other possible causes of oligomenorrhea. These include hyperandrogenic insulin-resistant acanthosis nigricans (HAIRAN), nonclassical congenital adrenal hyperplasia, 21-hydroxylase deficiency, hypothyroidism, hyperprolactinemia, androgen-secreting neoplasms, and cushing’s syndrome and cushing’s disease.
Treatment options for polycystic ovarian syndrome span a multitude of areas. They focus mainly on treating the insulin resistance and hyperandrogenism that characterize the disorder, and also on treating individual symptoms. They span from prescription medications to over-the-counter and alternative therapies. Two of the most common drugs used for polycystic ovarian syndrome (often combined into one regimen) are metformin (an insulin sensitizer) and spironolactone (a diuretic that also acts as an antagonist at androgen receptors around the human body. This combination has great success in many PCOS patients, and treats both of the underlying mechanisms of the disorder (Meriggiola, MD, PhD, C., & Zamah, MD, PhD, M. (Eds.), 2013). Other medications and nutritional supplements with similar and even identical actions are also used to treat these two medications. Examples of these include Spearmint tea (an androgen antagonist), and cinnamon extract (an insulin sensitizer). Most doctors however, will always use nutritional therapy and promotion of a low-glycemic index or low-carbohydrate diet as the first line of treatment for PCOS, as they increase insulin sensitivity.
The secondary focus is on treating the more minor symptoms and appearance-related symptoms caused by PCOS. Antibiotics and topical medications such as clindamycin and tretinoin are used for acne, hidradenitis, and other integumentary effects of the condition. Other topical medications can even block excess hair growth and hirsutism. For women who have oligomenorrhea and anovulation, oral contraceptives are often to used to promote the continuation of menstruation, and ovulation-inducing drugs are often used for women who want to get pregnant. Secondary conditions such as obesity are commonly treated with weight-loss promoting drugs, and obstructive sleep apnea with a continuous positive airway pressure (CPAP) machine (Meriggiola, MD, PhD, C., & Zamah, MD, PhD, M. (Eds.), 2013).). Depression and anxiety, which are a common occurrence in patients with PCOS, are most often treated with psychiatric medications. The ovarian cysts themselves are often removed through ovarian surgery if they do not resolve themselves.
If PCOS is left untreated and unmanaged, polycystic ovarian syndrome can cause the patient to have severe long-term health consequences (PCOS Health Risks., n.d.). The main long-term consequence, one which is a common prompt for women to find out if they have PCOS, is infertility. A woman with polycystic ovarian syndrome, at the onset of the condition, will most likely start to have fewer and more infrequent ovulation and menstruation. If left untreated, this can progress to a complete halt in the woman’s ovulation, leaving them unable to become pregnant (PCOS Health Risks., n.d.).
With hyperandrogenism, through a complicated feedback loop, comes insulin resistance, which leads to obesity if the insulin resistance and excess androgens are left untreated. This obesity can cause obstructive sleep apnea (due to increased adipose tissue around the airway), increased low-density lipoprotein (LDL) cholesterol, increased serum triglycerides, increased risk of myocardial infarction, venous thrombosis, and cerebral infarction, and even type two diabetes if it has progressed far enough. Due to the lack of menstruation also common in PCOS, the monthly build of blood in the endometrium does not have the chance to be excreted from the body. This buildup of endometrial tissue also greatly increases the risk of endometrial cancer later in life for women with untreated polycystic ovarian syndrome (PCOS Health Risks., n.d.).
Polycystic ovarian syndrome (PCOS) is a complex condition caused by an imbalance of testosterone in the female body. Occurring in up to 8% of females, it is the most common endocrine disorder among adult women. In order for a woman to be diagnosed with the condition, she must meet of the three Rotterdam Criteria, and her doctor must rule out all other possible causes of her symptoms, which include lack of menstruation, abnormal hair growth, and obesity. Once diagnosed, the patient’s condition must be properly managed with the use insulin-sensitizing and androgen-blocking drugs in order to prevent long-term consequences of PCOS, such as type two diabetes, endometrial cancer, and infertility. Secondary symptoms and issues associated with polycystic ovarian syndrome are also treated in order to improve the patient’s quality of life. If diagnosed and managed properly, a patient with PCOS can avoid the long-term consequences of her medical condition and remain healthy.
Karnath, MD, B. M. (2008, October). Signs of Hyperandrogenism in Women. Hospital Physician, 25-30.
Lujan, M. E., Chizen, D. R., & Pierson, R. A. (2008). Diagnostic Criteria for Polycystic Ovary Syndrome: Pitfalls and Controversies. Journal of Obstetrics and Gynecology Canada : JOGC = Journal D’obstetrique et Gynecologie Du Canada : JOGC, 30(8), 671–679.
Mayo Medical Laboratories. (n.d.). Test ID: EEST, Estradiol, Serum. Retrieved June 22, 2017, from http://www.mayomedicallaboratories.com/test-catalog/Clinical and Interpretive/81816
Mayo Medical Laboratories. (n.d.). Test ID: TTBS, Testosterone, Total and Bioavailable, Serum. Retrieved June 24, 2017, from http://www.mayomedicallaboratories.com/test-catalog/Clinical and Interpretive/80065
Second source from Mayo Medical Laboratories
Meriggiola, MD, PhD, C., & Zamah, MD, PhD, M. (Eds.). (2013, May). Polycystic Ovary Syndrome (PCOS). Retrieved June 22, 2017, from http://www.hormone.org/diseases-and-conditions/womens-health/polycystic-ovary-syndrome
PCOS Health Risks. (n.d.). Retrieved June 24, 2017, from http://www.uchospitals.edu/specialties/pcos/risks.html