Polycystic Ovarian Disease - PCOD

Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disorder, affecting about 5% of women.  In PCOS, excessive amounts of androgens (“male” hormones such as testosterone) are produced by the ovaries. PCOS is a common cause of infertility, menstrual irregularity, and hirsute (excessive hair growth). Until very recently, the most widely accepted dentition of PCOS was based upon the diagnostic criteria recommended in 1990 which classified PCOS as a disorder characterized by chronic hyperandrogenism(elevation of serum testosterone or other androgens) and chronic an ovulation(absence of ovulation) in the absence of other specific causes of these problems. More recently, an international consensus in 2003 expanded the definition of PCOS to include women who demonstrate two of the following three character-istics: 1) chronic an ovulation; 2) chronic hyperandrogenism; and 3) polycysticappearing ovaries (PCO) on ultrasound.

Without these criteria, a woman should not have a diagnosis of PCOD. Although, she may have irregular cycles, and “act” clinically like PCOD, her diagnosis is hypothalamic-pituitary dysfunction (HPD). This distinction is important to make because PCOD and HPD, although clinically similar in presentation and some long term consequences, ACFS has found they can behave differently in response to fertility medication, egg and embryo quality and risk of overstimulation and OHSS.

Women who have PCOS may have irregular, infrequent menstrual cycles, hirsutism, acne and/or infertility.  Many, but not all women (50%) with PCOS have ovaries enlarged with many small cysts (fluid-filled sacs), that are visible on ultrasound. Polycystic appearing ovaries are also seen in approximately 20% of women with normal menstrual cycles. Because of the variable nature of PCOS, its diagnosis is based upon the combination of clinical, ultrasound and laboratory features. A hallmark laboratory sign of PCOD, is a reverse ratio of FSH to LH. These tests can easily be measured in the blood and normally show an equal ratio of FSH to LH or, FSH being slightly higher than LH. In PCOD, the ratio is reversed with a 3:1 of LH:FSH.

Lack of ovulation in women with PCOS results in continuous exposure of their uterine lining (endometrium) to estrogen. This may cause excessive thickening of the endometrium and heavy, irregular bleeding.  Over many years, endometrial cancer may result due to the continuous stimulation of the endometrium by estrogen unopposed by progesterone, which is only produced if ovulation occurs. Statistically, woman with PCOD are at a 4-8x higher risk than woman with regular ovulatory cycles. The treatment for these women is either pregnancy; or if that is not an option, than regular withdrawal bleeds (every 1-2 months) with some progesterone agent. Women with PCOS may be also at increased risk for developing a metabolic syndrome, which mischaracterized by abdominal obesity, cholesterol abnormalities, hypertension, and insulin resistance that impairs blood sugar regulation. Women with PCOS have an increased risk for developing Type 2 diabetes, and possibly heart disease too. Obesity is common in women with PCOS. Diet and exercise that result in weight loss improves the frequency of ovulation, improves fertility, lowers the risk of diabetes, and lowers androgen levels in many women with PCOS; and is therefore, an important component of therapy.  Increasing physical activity is an important step in any weight reduction program.

If you are diagnosed with PCOS, treatment will depend upon your goals. Some patients are primarily concerned with fertility, while others are more concerned about menstrual cycle regulation, excess hair growth (hirsutism), and/or acne. Regardless of your primary goal, PCOS should be treated because of the long-term health risks it poses. If fertility is your immediate goal, ovulation may often be induced with clomiphene citrate (Clomid®, Serophene®), an orally administered fertility medication. Treatment with medications that increases your body's sensitivity to insulin, such as metformin (Glucophage®),may lead to more regular ovulation. Gonadotrophins, may be used to induce ovulation if you do not respond to simpler treatments. Gonadotropin therapy, however, is more expensive and associated with a greater chance of multiple pregnancy and side effects than oral therapies but does have, statistically, higher success rates in a shorter period of time. If fertility is not an immediate concern, hormonal therapies are usually successful in temporarily correcting the problems associated with PCOS. Oral contraceptive pills (OCAs) are commonly prescribed to reduce hirsutism and acne, maintain regular menstrual periods, prevent endometrial cancer, and prevent pregnancy.  OCAs may be combined with medications that decrease androgen action, such as spironolactone, to improve hirsutism. If OCAs are medically contraindicated, the treatment for these woman is either pregnancy; or if that is not an option, than regular withdrawal bleeds (every 1-2months) with some progesterone agent to decrease the risks of endometrial cancer in 20-30 years.

A surgical procedure, known as wedge resection of the ovaries, where a portion of the ovary is removed to decrease the amount of androgens produced by a PCOD ovary, although having had good success, has been abandoned because of concerns about the formation of pelvic adhesions, resulting infertility, and loss of valuable ovarian tissue. Ovarian diathermy or laser drilling has been used in recent years with apparently good results; however, a recent systematic review comparing drilling with Clomid and gonadotrophins (HMG) proved equivalent and therefore, ACFS does not recommend ovarian drilling as a treatment for PCOS. Vaniqa® cream and spironolactone (a mild fluid pill) have been approved to reduce facial hair.  Methods that remove hair, such as electrolysis and laser, are also helpful. Dealing with PCOS can be emotionally difficult. Women with PCOS may feel self conscious about their excessive hair growth or weight, as well as worry about their ability to have children but there are a number of successful medical modalities that can effectively reduce the side-effects and achieve pregnancy.

The American Society for Reproductive Medicine grants permission to photocopy the above fact sheet and distribute the above information it to patients.