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Polycystic ovary syndrome (PCOS), previously known as Stein-Leventhal syndrome, is a disorder in which numerous benign cysts form on the ovaries under a thick, white covering. It is most common in women under 30 years old and many ovarian cysts disappear without treatment.
The ovaries are the female reproductive organs that contain and release eggs. They also produce the female hormones estrogen and progesterone. Ovarian cysts are fluid-filled sacs that result from ovulation cycles; the most common are just enlargements of the normal egg follicles.
Incidence; Causes & Development
Between 5 and 30% of women have some characteristic of PCOS. This is one of the most common hormonal abnormalities in women of reproductive age and is a leading cause of infertility. Often in PCOS patients, periods start at the usual age of 12-13, while some start menstruating earlier. Interestingly, there appear to be variations of PCOS clinical manifestations among races. For example, obesity and hirsutism are not prominent among Japanese people, whereas they are much more common among Caucasians.
Polycystic ovary disease is due to an abnormal production of two of the hormones produced by the pituitary gland in the brain. These two hormones are LH (luteinizing hormone) and FSH (follicle-stimulating hormone). Imbalance of these hormones prevents the ovaries from releasing an egg each month. It also results in an increased production of the male hormone testosterone by the ovaries.
Signs & Symptoms
Because it is a syndrome, PCOS includes a set of symptoms. Women with PCOS can suffer from any combinations of the usual symptoms. Some women experience only one of these symptoms, while other women experience all of them. The severity of PCOS symptoms can vary widely from woman to woman.
Diagnosis & Tests
A doctor diagnoses polycystic ovary disease with tests and exams including the patient's medical history, a physical exam, blood tests to check hormone levels and an ultrasound.
Treatment & Prevention
The method of treatment depends upon the severity of the symptoms and whether you are trying to get pregnant. If you are not trying to conceive, you can be treated with hormones, including the birth control pill. Hormones and birth control pills will give regular menstrual cycles and may reduce abnormal hair growth. They also reduce the risk of developing endometrial hyperplasia, a condition that can become uterine cancer. If you are trying to become pregnant, your health care provider may prescribe fertility drugs, but it can be a long and complicated treatment.
In rare cases a wedge of ovarian tissue may be surgically removed or destroyed. This usually results in regular menstrual cycles for a while. For excess body and facial hair, your health care provider may recommend electrolysis.
It is desirable to have a period at least at intervals, though not necessarily monthly. Hormonal treatment, including the use of natural progesterone, can achieve this where required. The natural approach to PCOS should involve using all of the appropriate therapies at the same time and may require several months before improvement is seen.
The conventional treatment of PCOS is directed primarily at the problems of hirsutism, menstrual irregularity and infertility. Treatment modalities for hirsutism include ovarian and adrenal suppression, anti-androgen therapy and local hair removal measures. Oral contraceptives are simple and relatively safe method of ovarian suppression, in addition the estrogen component increases the sex hormone binding globulin (SHBG) with a resultant decrease in free testosterone. When DHEA-S levels are elevated, the addition of dexamethasone may be helpful. Spironolactone is the preferred anti-androgenic compound. It competitively inhibits intracellular dihydrotestosterone receptors within the hair follicles. Both cimetidine and cyproheptadine (a serotonin and histamine antagonist) have weak anti-androgenic effects.
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Signs, symptoms & indicators of Polycystic Ovary Syndrome (PCOS):
Conditions that suggest Polycystic Ovary Syndrome (PCOS): | | | | | Circulation |  Coronary Disease / Heart Attack | Women with the PCOS have a five to seven times higher risk of myocardial infarction and ischemic heart disease than other women. Surprisingly, the increased risk was found to be independent of obesity, supporting the argument that insulin resistance alone is important in determining cardiovascular risk. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899] |
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Hormones |
 Hirsutism| | It has been a tradition to divide patients with hirsutism into those with no elevation of serum androgen levels and no other clinical features ('idiopathic hirsutism') and those with an identifiable endocrine imbalance (most commonly PCOS or rarely other causes). However, in recent years it has become apparent that most patients with 'idiopathic hirsutism' have some radiological or biochemical evidence of PCOS on more detailed investigation. |
High Female Testosterone Level
Low Sex Hormone Binding Globulin |
Laboratory Test Needed |
Elevated Insulin Levels| | Researchers found that 75% of women studied with PCOS were hyperinsulinemic. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899] |
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Metabolic |
Problems Caused By Being Overweight |
Organ Health |
Diabetes Type II| | By the age of 40, up to 40% of women with PCOS will have Type II diabetes or impaired glucose tolerance. |
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Skin-Hair-Nails |
Adult Acne| | Among women with resistant acne (acne not responding to conventional treatments), PCOS is very common. |
Adolescent Acne |
Uro-Genital |
Amenorrhea| | In many women with polycystic ovaries, menstruation begins at the normal age. After a year or two of regular menstruation, the periods become highly irregular and then infrequent. |
Female Infertility| | Impaired fertility is a prominent feature of PCOS. This is believed to result from elevated insulin levels that stimulate excess androgen production by the ovaries. The androgens cause premature follicular wasting which causes inconsistent or absent ovulation, which in turn is associated with infertility. |
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Risk factors for Polycystic Ovary Syndrome (PCOS): | | | | | Childhood | Early puberty onset| | Some research suggests that girls who begin to develop pubic hair early (usually before the age of eight, a condition known as premature pubarche) have been found to have many of the signs and symptoms of PCOS. When girls with premature pubarche have been followed throughout the rest of puberty they have been found to develop excess testosterone production and irregular periods consistent with PCOS. Thus premature pubarche may be an early form of PCOS. |
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Polycystic Ovary Syndrome (PCOS) suggests the following may be present: | | | | | Laboratory Test Needed |  Elevated Insulin Levels| | Researchers found that 75% of women studied with PCOS were hyperinsulinemic. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899] |
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Polycystic Ovary Syndrome (PCOS) can lead to: | | | | | Metabolic | Problems Caused By Being Overweight |
Uro-Genital |
Female Infertility| | Impaired fertility is a prominent feature of PCOS. This is believed to result from elevated insulin levels that stimulate excess androgen production by the ovaries. The androgens cause premature follicular wasting which causes inconsistent or absent ovulation, which in turn is associated with infertility. |
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Recommendations and treatments for Polycystic Ovary Syndrome (PCOS): | | | | | Diet |  Sugars Avoidance / Reduction| | A high sugar diet causes obesity with further insulin resistance and aggravation of PCOS. According to Jerilyn Prior, M.D., the increased insulin from sugar consumption stimulates androgen receptors on the outside of the ovary, causing a failure of ovulation and the typical PCOS symptoms of hirsutism and acne. |
Weight Loss |
Hormone |
 Natural Progesterone| | Many women with PCOS have had success using progesterone cream to help produce regular periods. |
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Lab Tests/Rule-Outs |
Test for Hormones| | The most worrisome consideration in PCOS is the presence of an androgen-producing neoplasm. It is for this reason that a measurement of total testosterone and DHEA is recommended. |
Ultrasound |
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KEY | | Weak or unproven link | | | Strong or generally accepted link | | | Proven definite or direct link | | | Likely to help | | | Highly recommended |
GLOSSARY
Acne
A chronic skin disorder due to inflammation of hair follicles and sebaceous glands (secretion glands in the skin).
Adrenal (Adrenal Gland, Adrenal Glands, Adrenals)
The adrenal glands sit on top of each kidney and consist of an outer cortex and an inner medulla. Of the 50 or so hormones the adrenals make, only cortisone and adrenaline are recognized by most people. Some of these hormones must be produced to preserve life, while others help resist stress. Other hormones from the adrenals control normal energy output (along with the thyroid) and govern the breakdown of stored energy into quick energy sources. The medulla produces epinephrine and norepinephrine, which are specifically designed to help the body deal with stressful situations. The adrenals control the body's potassium/sodium balance, which is vital for energy production. They also produce sex hormones in minute amounts, which is important for later years when the gonads drop or cease their production.
Androgen
Any steroid hormone that increases male characteristics.
Benign
Literally: innocent; not malignant. Often used to refer to cells that are not cancerous; they tend to grow slowly and don't spread (metastasize) like cancer tumors do.
Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
Cardiovascular
Pertaining to the heart and blood vessels.
Cysts (Cyst)
A closed pocket or pouch of tissue; a cyst may form within any tissue in the body and can be filled with air, fluid, pus, or other material. Cysts within the lung generally are air-filled, while cysts involving the lymph system or kidneys are fluid filled. Cysts under the skin are benign, extremely common, movable lumps. These may develop as a result of infection, clogging of sebaceous glands, developmental abnormalities or around foreign bodies.
DHEA (DHEA-S)
Dehydroepiandrosterone (DHEA) is a steroid produced by the adrenal glands and is the most abundant one found in humans. DHEA may be transformed into testosterone, estrogen or other steroids. It is found in the body as DHEA or in the sulfated form known as DHEA-S. One form is converted into the other as needed.
Diabetes Mellitus (Diabetes, Diabetic, Diabetics)
A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.
Dihydrotestosterone (DHT)
A highly active form of testosterone, which influences many aspects of manly behavior, from sex drive to aggression. The conversion from testosterone to DHT is driven by an enzyme called 5-alpha reductase, which is produced in the prostate, various adrenal glands, and the scalp.
Estrogen (Oestrogen)
One of the female sex hormones produced by the ovaries.
Glucose
A sugar that is the simplest form of carbohydrate. It is commonly referred to as blood sugar. The body breaks down carbohydrates in foods into glucose, which serves as the primary fuel for the muscles and the brain.
Histamine
A chemical in the body tissues, produced by the breakdown of histidine. It is released in allergic reactions and causes widening of capillaries, decreased blood pressure, increased release of gastric juice, fluid leakage forming itchy skin and hives, and tightening of smooth muscles of the bronchial tube and uterus. Histamine is the chemical that drives the initial acute allergic reaction, causing itching, swelling and congestion.
Hormones (Hormone)
Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.
Idiopathic
Arising spontaneously or from an obscure or unknown cause.
Insulin
A hormone secreted by the pancreas in response to elevated blood glucose levels. Insulin stimulates the liver, muscles, and fat cells to remove glucose from the blood for use or storage.
Ischemia (Ischemic)
Localized tissue anemia due to obstruction of the inflow of arterial blood. A decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels.
Lipid (Lipids)
Fat-soluble substances derived from animal or vegetable cells by nonpolar solvents (e.g. ether); the term can include the following types of materials: fatty acids, glycerides, phospholipids, alcohols and waxes.
Luteinizing Hormone
Anterior pituitary hormone stimulating estrogen production by the ovary; promoting formation of progesterone by the corpus luteum in women and stimulating testosterone release in men.
Menstruation (Menses, Menstrual, Menstrual Cycle, Menstrual Cycles, Menstrual Flow, Menstrual Phase, Monthly Cycle)
The periodic discharge of blood, tissue fluid and mucus from the endometrium (lining of the uterus) that usually lasts from 3 - 5 days. It is caused by a sudden reduction in estrogens and progesterone.
Ovarian Cysts (Ovarian Cyst)
These occur in two forms, namely "functional" and "organic". Symptoms may not be present but can include pressure or pain in the abdomen, problems with urine flow or pain during sexual intercourse. Rarely, a very large cyst can become twisted and stop its own blood supply, possibly causing nausea, fever or severe abdominal pain. Functional ovarian cysts form part of the normal functioning of the ovary and are always benign. They may be either "follicular cysts", produced by all menstruating women every month and reaching up to 2-3cm in diameter before they rupture at ovulation, or "corpus luteum cysts", which appear after ovulation and may grow to produce "hemorrhagic cysts" if ovulation does not occur or is delayed. Rupture of such a cyst can sometimes cause painful ovulation or bleeding, which is often moderate and resolves by itself. Organic ovarian cysts may be benign or malignant and are not linked to the functioning of the ovary. They occur as either "dermoid cysts", which are benign tumors that may nevertheless recur on either ovary and contain elements derived from the skin (hairs, sebum, teeth), or other organic cysts.
Ovary (Ovaries)
Ovaries are about the size of an almond and lie on either side of the lower abdomen beside the uterus. They usually produce one egg each month and whether the egg is fertilized or not, the reproductive process follows a monthly cycle, with constant changes in various hormone levels, preparing another opportunity for conception. The ovary is responsible for most of the estrogen production in women. At menopause (sometime after middle-age), egg production ceases and hormone levels drop significantly.
Pituitary (Pituitary Gland)
The pituitary gland is a small (half-inch), bean-shaped organ that hangs down from the lower center of the brain on a stalk attached to another gland, the hypothalamus. Weighing less than one gram, the pituitary gland is often called the "master gland" since it controls the secretion of hormones by other endocrine glands. It regulates many body activities, and is partitioned into front and back lobes. The front lobe is stimulated by the hypothalamus, and produces any one of six different hormones that in turn stimulate the thyroid, adrenal and reproductive glands, and also breast milk production.
Progesterone
This is the hormone secreted after ovulation by the corpus luteum. It is a steroid (similar to a cholesterol), enters receptive cells to stimulate their growth, and acts as an anabolic agent. Estrogen should be viewed as the primary coat underneath all the cycles during a woman's reproductive years, with progesterone, its antagonist, surging for ten or twelve days in ovulatory months. Most of the actions of progesterone cannot occur without estrogen having previously induced the growth of progesterone-receptive binding sites.
Serotonin
A phenolic amine neurotransmitter (C10H12N2O) that is a powerful vasoconstrictor and is found especially in the brain, blood serum and gastric membranes of mammals. Considered essential for relaxation, sleep, and concentration.
Serum
The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.
SHBG (Sex Hormone Binding Globulin, Sex Hormone-Binding Globulin)
A glycoprotein, synthesized in the liver, which binds testosterone and 5 alpha-dihydrotestosterone strongly, and estradiol somewhat less strongly. Circulating testosterone is mainly bound to protein - primarily SHBG, but also to albumin and cortisol-binding globulin. Since variations in the carrier protein levels may affect the concentration of testosterone in circulation, SHBG levels are commonly measured as a supplement to total testosterone determinations. The "free androgen index" (FAI), calculated as the ratio of total testosterone to SHBG, has proved to be a useful indicator of abnormal androgen status in conditions such as hirsutism.
Syndrome
A medical condition characterized by a collection of related symptoms (what the patient feels) and signs (what a doctor can observe or measure).
Testosterone
The principal male sex hormone that induces and maintains the changes that take place in males at puberty. In men, the testicles continue to produce testosterone throughout life, though there is some decline with age. A naturally occurring androgenic hormone.
Ultrasound
Ultrasound testing uses sound waves projected into the body to produce an image of internal organs, structures, tumors, etc. In this procedure, a gel is applied to the patient's skin, and a small device that emits ultrasonic pulses is slowly passed over the area. The sonic image produced is viewed on a monitor.
Uterus (Uterine)
The part of the female reproductive system specialized to allow the implantation, growth and nourishment of a fetus during pregnancy.
Last updated: Feb 28, 2010
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