Polycystic ovary syndrome (PCOS) is a medical condition in which women experience irregular or absent menstrual bleeding, increased hair growth, infertility, and excessive weight gain. This syndrome was first described in 1935 by Drs. Stein and Leventhal, and for many years PCOS was known as the Stein-Leventhal Syndrome. Women wth PCO have enlarged ovaries containing multiple small cysts which have led to the descriptive term, polycystic ovaries. PCOS is comprised of several clinical features, each of which may be present to a lesser or greater degree. Some women have been found to have polycytic ovaries without associated abnormalities of menstruation, hair growth, weight gain or infertility. These womem do not have Polycystic Ovary Syndrome. Thus, not all women with polycystic ovaries have PCOS, but all women with PCOS have polycystic ovaries.

The abnormal hormone action seen in PCOS can best be understood by first discussing the normal hormone patterns required for ovulation. There are two hormones secreted by the pituitary gland in the brain. They are FSH (follicle stimulating hormone) and LH (luteinizing hormone). FSH acts on the ovarian follicle to stimulate maturation of the egg or ovum. At the time of ovulation, there is a surge of LH which in part is responsible for rupture of the follicle and release of the egg. The ruptured follicle then becomes the corpus luteum. Under stimulation of LH, the cells that make up the corupus luteum undergo a luteinizing process. In the patient with PCOS, a variety of any of these hormones may be produced at an abnormal level, perpetuating incomplete follicular development without consistent ovulation. Since the hormonal system operates as a feed-back loop, when any hormone is at an abnormal level, all related hormones are affected. Specifically, LH levels can be higher than normal resulting in an increased LH/FSH ratio, with stimulation of the ovarian follicle but not resulting in maturation and release of the egg. The elevated LH levels stimulate luteinization of the cells surounding the follicle, which results in a shift in ovarian hormone production towards increasing testosterone levels and indirectly a change in estrogen levels. This feeds back on the LH/FSH production and can affect the normal ratio. Therefore, not only are there the peripheral effects of increased testosterone production (increasing hair growth) but also menstrual dysfunction.

Women with PCOS have normal reproductive organs such as the uterus and fallopian tubes. Their ovaries each contain multiple small cysts around the periphery, each ovarian cyst generally measuring less than 8 mm diameter and easily seen by pelvic ultrasound. These cysts do not appear to grow and usually remain small. They do not require surgical removal and are not associated with an increased risk of ovarian cancer.

The symptoms of PCOS: -Menstrual irregularities (either no menses or very heavy bleeding) -Impaired fertility, usually due to the womanÕs inability to ovulate regularly -Miscarriage rates are higher due to elevated LH level on egg development and uterine lining -Hair & Skin problems (increased hair growth and acne from elevated testosterone) -Obesity (about 50% of women with PCOS are obese) -Abnormal Insulin Action (PCOS patients have a greater long-term risk of developing diabetes mellitus) -Heart Disease (PCOS women may be at a long-term increased risk of heart disease due to the unfavorable lipid profile produced by elevated androgens) -Breast milk secretion (30-40% of PCOS patients have an elevated serum prolactin level.
Prior to initiating fertility treatment, other factors which impact fertiity are usually evaluated. These factors include tubal patency, pelvic anatomic relationships, assessment of semen and sperm function, cervical mucous quality, presence of immunologic causes of infertility and uterine anatomical abnormalities. In women with PCOS, failure to ovulate is the usual reason for not achieving pregnancy.

Treatment of PCOS: In cases where ovulation is irregular or absent, medication can be used. The most common agent is clomiphene citrate (Clomid, Serophene), which is generally taken daily from days 3-7 of a cycle. Ovarian follicle development is usually monitored with a combination of home urinary LH testing, and office ultrasound examination. An intrauterine insemination is frequently advised because of clomipheneÕs adverse effect on a womanÕs cervical mucous quality. Additional endometrial support may be promoted with the use of progesterone or HCG injections. There is a mildly increased rate of multiple pregnancy with clomiphene (6-7%) but there is no increased risk of birth defects. The majority of womn who conceive on clomiphene will do so in the first 4 cycles. If clomiphene fails to successfully induce ovulation and/or pregnancy, then a group of injectable hormone preparations, known as gonadotropins, may be employed.

There are two types of gonadotropin preparations available. One contains both FSH and LH, the other only FSH. Although both types of gonadotropins work well in women with PCOS, many fertility specialists prefer to use the products which contain primarily FSH (Metrodin). Therapy includes daily injections, with careful monitoring of ovarian follicle development by serum estradiol hormone measurements and pelvic ultrasound examinations. When optimum growth and development of the follicle(s) has occured, administration of human chorionic gonadotropin (hCG) is administered to stimulate release of the egg(s) from the follicle(s). The risk of multiple pregnancy is increased with gonadotropin therapy (16-18%), and women with PCOS given gonadotropins are at an increased risk of an uncommon but potentially serious condition known as Ovarian Hyperstimulation Syndrome. This situation arises if an excessive number of follicles are stimulated. Avoidance of Ovarian Hyperstimulation Syndrome is best achieved by careful monitoring of ovulation induction. This is the reason that virtually all fertility specialists are available 365 days a year for office ultrasound and clinical monitoring for all patients on gonadotropins.

Laparoscopic laser ÒdrillingÓ of the ovarian capsule is another treatment for PCOS. This usually results in resumption of regular ovulatory function. In some cases, regular ovulation persists for some time, whereas in other patients, irregular or absent menstrual function recurs.

In Vitro Fertilization (IVF) may also be offered to women with PCOS who wish to conceive after other treatment strategies have failed. Success (pregnancy) rates with IVF in PCOS patients are generally excellent, although a higher risk of Ovarian Hyperstimulation exists, especially in IVF patients who become pregnant.

In summary, PCOS is the most common cause of menstrual irregularity in reproductive-aged women and its occurrence may be associated with a variety of clinical symptoms, including infertility. There are known long-term health risks associated with PCOS. As a result, patients with this condition are advised to seek medical assistance since current therapies and treatments exist, which may prove very beneficial.

Copyright 2000-2005 Donald I. Galen, M.D. 
Physician partner in the Reproductive Science Centerª of the San Francisco Bay Area
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