One of the most common barriers to getting pregnant is Polycystic Ovarian Syndrome (PCOS), a disorder that affects between 4% and 12% of the female population. PCOS causes a woman’s ovaries to become enlarged and develop a number of small cysts inside. Because women with PCOS rarely ovulate (release eggs), they have very irregular periods and cannot conceive.
PCOS is associated with a number of hormone imbalances. For example, women with PCOS usually produce too little progesterone and too much estrogen (two key female hormones). As a result, some only get a “period” every 2 to 4 months, and others go even longer without bleeding at all. In between periods, the lining of the uterus continues to build up and thicken so when it finally sheds, the bleeding can be heavy.
Women with PCOS also produce too much androgen – a male hormone – which triggers “masculine” symptoms such as course hair growing on the face, chest, back, abdomen and inner thighs. Androgens can also cause the skin to get oily and develop acne. In addition, women with PCOS don’t respond normally to insulin, a hormone that regulates blood sugar. In response, their bodies produce extra insulin, which makes their symptoms even worse.
The Link to Obesity
PCOS is closely associated with obesity – in fact, the majority of women with PCOS are significantly overweight. Obesity contributes to the hormone imbalances of PCOS, worsening irregular bleeding and unwanted hair growth. Left untreated, PCOS can lead to serious health problems like diabetes and heart disease.
There is good news, however: The cysts that appear in PCOS can be detected by ultrasound. They usually remain small, do not require surgical removal, and are not associated with ovarian cancer. And perhaps the best news of all is that for many obese women with PCOS, just losing 5% to 10% of their body weight will allow them to resume normal, regular ovulation. Weight reduction is also associated with reduced levels of androgen, improved response to insulin, better cholesterol levels, and lowered risk for heart disease.
For women in the reproductive age range, polycystic ovary syndrome is a serious, common cause of infertility, because of the endocrine abnormalities which accompany elevated insulin levels. There is increasing evidence that this endocrine abnormality can be reversed by treatment with widely available standard medications which are leading medicines used in this country for the treatment of adult onset diabetes, metformin (Glucophage 500 or 850 mg three times per day or 1000mg twice daily with meals), pioglitazone (Actos 15-30 mg once a day), rosiglitazone (Avandia 4-8 mg once daily) or a combination of these medications. These medications have been shown to reverse the endocrine abnormalities seen with polycystic ovary syndrome within two or three months. They can result in decreased hair loss, diminished facial and body hair growth, normalization of elevated blood pressure, regulation or menses, weight loss, reduction in cardiovascular risk factors, normal fertility, and a reduced risk of miscarriage. We have seen pregnancies result in less than two months in woman who conceived in their very first ovulatory menstrual cycle. By six months over 90% of women treated with insulin-lowering agents, diet and exercise will resume regular menses.
Medical Treatments
When weight loss alone will not bring on ovulation, ovulation must be induced medically. A number of different medications and approaches are available.
Before choosing a treatment, the physician should rule out other possible reasons for infertility such as problems with the uterus or fallopian tubes, hormone problems besides PCOS, or problems with the partner’s sperm. Once these possibilities are eliminated, doctors commonly start treatment with a pill called clomiphene citrate (CC) to correct the hormone imbalances. Approximately 80% of women with PCOS are able to ovulate when treated with CC, although the response rate is somewhat lower in obese women.
Generally, clomiphene citrate has few or mild side effects, including hot flashes, upset stomach or bowels, headaches, sensitivity to bright light, visual disturbances, mood swings, and breast tenderness. Clomiphene citrate may also result in multiple pregnancy (5 to 10 percent of pregnancies will be twins). Prolonged use of clomiphene citrate may increase the risk of ovarian cancer. Women should discuss this concern, and all safety concerns, with their healthcare provider.
Women taking clomiphene have to monitor their monthly cycle closely to determine whether the treatment is working. Patients track their temperature every morning with a specially sensitive thermometer (known as a “basal body thermometer”) that can detect the slight rise in temperature that occurs after ovulation. Ovulation can also be confirmed through ultrasounds or blood tests.
Women who don’t respond to clomiphene are often treated with a type of injectable medication called a gonadotropin. Gonadotropins contain either FSH alone or FSH plus LH, two female hormones that induce ovulation. Women taking gonadotropins sometimes release more than 1 egg in a given cycle, which can lead to multiple births of triplets or more. Physicians closely monitor women receiving gonadotropins to avoid multiple births. If the risk for multiples is too high, treatment is usually stopped for that cycle.
Women with PCOS must also be monitored for a serious medical condition known as ovarian hyperstimulation syndrome (OHSS). When medication causes a large number of eggs to develop, the ovaries can enlarge and leak fluid into the abdomen. This can create severe pelvic pain, sudden weight gain, nausea, and vomiting. Severe cases of OHSS can lead to more serious complications that require hospitalization.
Another approach to treating PCOS involves minor surgery known as ovarian cautery. Androgen, the male hormone, is released from the center of the ovary. Destroying a small portion of the ovary with an electrical current (a procedure called “cautery”) often reduces androgen production. Ovarian cautery is carried out under general anesthesia and done by laparoscopy (guiding a needle through a very small cut near the navel). The needle punctures the ovary and delivers enough electrical current to destroy a bit of tissue. While ovarian cautery carries a risk of creating scar tissue on the ovary, it is often successful at lowering androgen and allowing women to ovulate.
If these treatments fail, there is still another option: In Vitro Fertilization (IVF). In IVF, eggs are removed from a woman’s ovaries, fertilized with her partner’s sperm in a laboratory, and then returned to her uterus to develop into a baby. Various drugs are used to help create and maintain the pregnancy.
PCOS is a serious disorder that poses long-term health risks. But proper diagnosis and treatment of PCOS – including healthy lifestyle changes – can greatly improve a woman’s health, her symptoms, and her chances for having a baby.
