Information for health care professionals on polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common hormonal endocrine condition that affects approximately 5% to 10% of females of reproductive age, depending on the diagnostic criteria used, according to the American College of Obstetricians and Gynecologists (ACOG).

PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Its etiology remains unknown, and treatment is symptom-based and empirical. The disorder can result in substantial metabolic sequelae, including an increased risk of diabetes and cardiovascular disease, which should be considered when determining long-term treatment.

Signs and symptoms of PCOS

Symptoms usually appear in adolescents and women in their early 20s but may appear later because hormonal changes vary in women. Primary care providers should watch for:

  • Oligomenorrhea or amenorrhea (periods that occur infrequently or no periods)
  • Heavy periods or unpredictable periods
  • Obesity (4 out of 5 women with PCOS are overweight or obese)
  • Infertility
  • Ovaries that appear polycystic on ultrasound
  • Type 2 diabetes
  • Hirsutism of the face, chest, abdomen, or thighs (presents in 7 out of 10 women with PCOS)
  • Alopecia
  • Severe acne or acne that occurs after adolescence and doesn’t respond to treatments
  • Acanthosis nigricans (patches of thickened, velvety, darkened skin)
  • Weight gain
  • Fatty liver
  • Sleep apnea
  • Depression
  • Eating disorders

Women with PCOS usually have fewer than six to eight menstrual periods per year. Less is known about PCOS symptoms after menopause. Research suggests that women with PCOS may continue to have high androgen levels after menopause. Women whose hormone levels return to normal after menopause may still have symptoms, including excess hair growth. Comorbidities will continue to manifest after menopause.

Causes

The cause of PCOS is unknown. It may result from an unknown triggering event or be related to many factors working together. These factors include:

  • Insulin resistance that causes blood glucose to rise and ultimately leads to diabetes mellitus and acanthosis nigricans
  • Increased levels of androgens
  • An irregular menstrual cycle

Higher levels of androgen may prevent ovulation and cause hirsutism and acne. Irregular menstrual periods lead to infertility and, in some women, the development of polycystic ovaries. Some studies suggest that abnormal levels of luteinizing hormone from the pituitary gland and high levels of androgens interfere with the normal function of the ovaries.

Screening and diagnosis

An estimated 75% of patients with PCOS are unidentified in clinical practice due to the broad range of symptomology experienced by women with the condition. PCOS is clinically diagnosed when a woman exhibits two out of three of the Rotterdam criteria: oligo-anovulation or amenorrhea, a clinical or laboratory finding of hyperandrogenism, and/or polycystic ovarian morphology on ultrasound (12 follicles measuring 2 millimeters to 9 millimeters in diameter and/or an ovarian volume greater than 10 milliliters in at least one ovary). Diagnosis is based on symptoms, blood tests, and physical examination.

Physicians should rule out diagnoses with similar clinical presentations, including other causes of oligo-anovulation or amenorrhea and hyperandrogenism, before giving a diagnosis of PCOS, which is associated with psychological distress, anxiety, depression, and fears about future health and fertility. Other causes of elevated androgen levels or irregular periods include hypothyroidism, congenital adrenal hyperplasia, androgen-secreting tumors, and hyperprolactinemia.

According to research, a high percentage of women diagnosed with PCOS feel they either receive no information about the diagnosis or inadequate information.

After diagnosis, patients should be tested or monitored for metabolic syndrome, abnormal insulin sensitivity, Type 2 diabetes, elevated cholesterol and cardiovascular disease, obesity, and unopposed estrogens, which may lead to endometrial hyperplasia, endometrial polyps, endometriosis, and adenomyosis. Many clinicians who treat PCOS also recommend testing for sleep apnea by a sleep medicine specialist. Women with PCOS who are obese are at high risk for nonalcoholic steatohepatitis and should be screened for signs of liver fat and fibrosis.

All women who are diagnosed should be seen routinely by a clinician and observed for signs of depression, anxiety, and eating disorders. Sexual dysfunction may also affect the quality of life in women with PCOS.

Treatment and prognosis

Although there is no cure for PCOS, treatments are available to reduce or minimize patient symptoms. Most women with the condition can lead a normal life without significant complications. Treatment should be tailored to each patient according to her symptoms, other health problems, and whether she desires pregnancy.

For women who are overweight, even a small weight loss may help regulate the menstrual cycle. Weight loss also has been found to improve cholesterol and insulin levels and relieve symptoms such as hirsutism and acne.

Combination estrogen and progestin birth control pills can be used for long-term treatment in women with PCOS who don’t wish to become pregnant. In addition to regulating the menstrual cycle, they may reduce hirsutism and acne and decrease the risk of endometrial hyperplasia.

For women who want to become pregnant, the oral ovulation induction agent letrozole is the first-line pharmacological treatment for anovulatory infertility in women with PCOS and no other infertility factors. Insulin-sensitizing drugs can help decrease androgen levels and improve ovulation to help make menstrual periods regular.

Even though PCOS can’t be cured, it can be managed. Early diagnosis can help patients manage their symptoms and reduce the risk of long-term negative health effects.

  • Choose a low-glycemic diet.
  • Maintain a healthy weight.
  • Engage in regular exercise.
  • Use supplements as directed by your physician or dietitian.

Women diagnosed with PCOS at a UT Physicians Women’s Center are referred to the Polycystic Ovary Syndrome Program at UTHealth Houston, where they meet with a registered dietitian with special expertise in treating women with the condition. Recommendations are tailored to each patient’s condition, health problems, goals, and lifestyle.

Resources

The following organizations also provide reliable health information: