Polycystic Ovarian Syndrome The condition, polycystic ovarian syndrome, known as PCOS, is the commonest cause of ovulation disorders

in women of reproductive age and is a familial condition. Polycystic ovarian syndrome (PCOS), is a primary ovarian condition and is characterized by the presence of many minute cysts in the ovaries and excess production of androgens. Polycystic ovarian syndrome can be found in apparently normal women and the full expression of the disease so-called Steinleventhal syndrome is very uncommon. Polycystic ovarian syndrome is frequently associated with weight gain, excessive hair growth in the face and body, irregular and infrequent periods or absent periods, infrequent or absent ovulation, miscarriage and infertility. The cause of PCOS is not fully understood. There are long-term risks of developing type 2 diabetes, cardiovascular disease and cancer of the womb. Women diagnosed as having PCOS before pregnancy have an increased risk of developing gestational diabetes.

Incidence of Polycystic Ovarian Syndrome Polycystic ovarian syndrome (PCOS) accounts for 90% of women with oligomenorrhoea (infrequent periods) and 30% of women with amenorrhoea (absent of periods) and over 70% of women with anovulation.

Diagnosis of Polycystic Ovarian Syndrome Laparoscopy Laparoscopy allows direct inspection of the ovaries; the ovaries are enlarged and polycystic. However, polycystic ovaries may appear normal at laparoscopy. Vaginal ultrasound scan (better than abdominal) The vaginal ultrasound may show the typical PCOS appearance but reliability varies with expertise.

Blood hormone levels of LH, FSH, androgens and SHBG Ideally, these tests should be performed during the first four days of the cycle. If the women has no period, then the test can be performed anytime, and repeated if the results do not provide a clear picture. FSH levels are low or normal, LH levels are often raised. However, a normal level does not exclude diagnosis of polycystic ovarian syndrome (PCOS). The levels of androgens and testosterone may be raised. The American Society of Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) joint consensus meeting in November 2003 agreed that the diagnosis of PCOS should be made when two of the following three criteria are met:

Infrequent or absent ovulation Hyperandrogenism (clinical or biochemical) such as excess hair growth, acne, raised LH, and raised androgen index Polycystic ovarian morphology on ultrasound scan (>12 follicles measuring between 2 and 9mm in diameter) and/or ovarian volume >10ml. The distribution of the follicles are not required and with one ovary sufficient for diagnosis.

Treatment of Polycystic Ovarian Syndrome in women who wish to conceive

Weight loss if she is over weight This simple measure may restore menstruation and ovulation in patients with polycystic ovarian syndrome. Exercise and weight control also reduce the likelihood of developing type 2 diabetes in later life.

Ovulation induction with clomiphene (clomid) tablets Induction of ovulation with clomiphene tablets is the first choice and is an effective treatment of polycystic ovarian syndrome (PCOS). It results in restoring menstruation and ovulation in about 70% of women and some 30% will conceive within three months of treatment. Clomiphene tablets maybe combined with steroid tablets to suppress androgen production. If this fails after a six month trial, then controlled ovarian stimulation with FSH or hMG combined with hCG is used. Because the polycystic ovaries are usually sensitive to stimulation by hormones, it is important to start with a low dose and adjust the dose according to the response. Monitoring of treatment is essential because these patients are susceptible to develop ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Surgery Surgery is recommended should the medical treatment fail and for women who have experienced OHSS. This may be ovarian drilling or ovarian wedge resection. It is not clear why women with PCOS ovulate after ovarian drilling or wedge resection. After surgery, ovulation occurs spontaneously in 70-90% of women and the probability of pregnancy after one year is in the region of 40-60%. There is no increased risk of multiple pregnancy or OHSS. If ovulatory cycles fail to restore after the surgery, the doctor may restart ovulation induction. A recent study up to 20 years after laparoscopic drilling has shown persistance of ovulation over many years. Compared with medical treatment, it need only be performed once and intensive monitoring is not required. The main problems associated with surgery include adhesion formation, the risk of destruction of the ovaries leading to ovarian failure. In addition, there are risks associated with surgery and anesthesia. Laparoscopy showing polycystic ovaries

Laparoscopy showing ovarian drilling

Treatment of Polycystic Ovarian Syndrome (PCOS) in women who do not wish to conceive
Low-dose contraceptive pills are the best option to restore menstrual regularity. It will decrease ovarian hormone production and help reverse the effects of the excessive androgen levels. However, if you smoke and are over 35 years, birth control pills are not recommended. The doctor may prescribe other hormone treatments such as progesterone tablets. In women with hirsutism or severe acne, treatment with estrogens and anti-androgen such as cyproterone acetate (dianette) may be used.

Metformin
Many women with PCOS have decreased sensitivity to insulin, and their bodies overcompensate by over-producing insulin. Elevated levels of insulin are common in women with PCOS, whether they are obese or thin compared with weight matched controls. Some experts believe that this excess insulin is the underlying cause of PCOS because insulin stimulates androgen production and effects follicular development. As a consequence, Metformin (oral anti-diabetic drug) combined with Clomid, has been used to treat women with PCOS. Approximately 15% of women discontinue metformin pills because of side effects which are mainly gastrointestinal. Long-acting preparations are associated with fewer side effects. Insulin sensitizing drugs have not been licensed in the UK for use in non diabetic patients. Metformin should not be used when kidney function is abnormal.

Initial studies were encouraging; it reported successful restoration of regular menstrual cycles and fertility. More recent large randomised studies have not observed beneficial effects of metformin in the treatment of ovulation problems in women with PCOS (Human Reproduction 2008; 23:462-77). Furthermore, potential benefit from the use of metformin in PCOS women undergoing IVF treatment has been reported. It improves the live birth rates and reduces the incidence of severe ovarian hyperstimulation syndrome (Tange et al, 2006 Human Reproduction).