Polycystic Ovaries |
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Polycystic Ovary Syndrome (PCOS) is a medical condition that occurs in 4-12% of the population. These women may experience irregular or absent menstrual bleeding, increased hair growth, and difficulty becoming pregnant. Additionally, clinical features, include insulin resistance and obesity. In these women, the ovaries are slightly enlarged and contain multiple small cysts which have led to the descriptive term, polycystic ovaries. Thus, Polycystic Ovary Syndrome is comprised of several clinical features, each of which may be present to a greater or lesser degree. As a result, patients may seek medical advice to correct irregular menstruation, eradicate excessive hair growth, or achieve pregnancy.
Some women have been found to have polycystic ovaries without associated abnormalities of menstruation, hair growth or fertility. These women do not have Polycystic Ovary Syndrome. Thus, not all women with polysyctic ovaries have PCOS, but all women with PCOS have polycystic ovaries.
Women have two ovaries; they are located in the pelvis alongside the uterus. Their mainfunctions are to release eggs and produce hormones At birth, the ovaries are provided with approximately two million eggs, each surrounded by cells which develop into a small fluid filled blister known as a follicle.Each month in women with regular periods (normal ovulation), one of these follicles will develop and grow to about 20 mm in diameter and them release a mature egg (ovulation), which passes into the fallopian tubes. If there is fertilization, the fertilized egg (embryo) continues its course through the tube into the uterus where it will implant in the lining (endometrium) and develop as a pregnancy. If there is no fertilization, the endometrium is shed as a menstrual period around 14 days after ovulation. Three important groups ofhormones-estrogens, androgens and progesterone- are also produced in the ovary. These, in turn, are regulated by the release of two additional hormones follicle stimulating hormones (FSH) and luteinizing hormone (LH) from the pituitary gland which is located at the base of the brain. These two "reproductive" hormones influence the development of the follicle, maturation of the egg, and the timing of ovulation.
Women with POCS have normal reproductive organs such as the uterus and fallopian tubes.Their ovaries each usually contain about 10 or more small cysts generally are less than 8 mm and can be detected by ultrasound examination. These cysts do not appear to grow and usually remain small. They do not require surgical removal. Additionally, these cysts do not represent cancer and are not associated with an increased risk of ovarian cancer.
The Reason for multiple cyst development is not clear. It may be related to the inability of ovulation in women with PCOS. In comparison to normal ovulation, women with PCOS are usually unable to completely develop a fully mature egg ( on their own) due to abnormal pituitary FSH and LH secretion. As a result, the ovulatory process is not completed and the partially stimulated follicle becomes cystic followed by degeneration of the egg. Some researchers suggest that there may be a familial component or genetically determined ovarian defect. The cause is probably a combination of genetic and environmental factors (specifically excess weight) interacting and causing the abnormalities.
The problems of irregular or absent menstrual bleeding, excess hair growth and infertility are a result of abnormal hormone secretion by the pituitary gland (FSH and LH) and the ovaries (estrogen, androgen and progesterone). Despite irregular ovulation in PCOS, the ovary continues to be stimulated by FSH and LH in an uncoordinated manner, which leads to a constant production of estrogen, excessive amounts of androgen, and very little progesterone.
- Menstrual Irregularities: Constant estrogen production stimulates growth of the uterine lining, or endometrium. As the lining grows and becomes abnormally thickened, there can be spontaneous shedding of the endometrium. This process, together with the lack of regular ovulation, leads to irregular and, sometime, very heavy uterine bleeding. The bleeding episodes may occur after long gaps of time (oligomenorrhea) or, for some women, not at all (amenorrhea).
- Impaired Fertility: Another consequence of incomplete follicular development is a lack of regular ovulation, Irregular ovulation usually means that pregnancy is more difficult to achieve. Similarly, if ovulation is not taking place, it is not possible to conceive. In most instance of PCOS, some form of treatment is necessary to re-establish predictable ovulation.
- Miscarriage: While miscarriage seems an unfortunate chance event for most couples, it is thought that women with PCOS who have high circulating levels of LH may be at increased risk. A possible explanation is that levels of LH which are high in PCOS may interfere with egg development within the follicle and/or disrupt embryo implantation within the uterus.
- Hair and Skin Problems: Androgen (male hormone) is produced by ovaries from both normal women and those with PCOS. In PCOS the production of androgen, such as testosterone, is excessive, which causes abnormally increased hair growth and contributes to acne formation.
- Obesity: It has been previously reported that about 50 percent of women with PCOS are obese. However, the recent trend towards excessive weight gain in the United States population suggests a greater incidence of obesity in PCOS women. Obesity tends to enhance abnormal estrogen and androgen production in this disorder, which only magnifies the problems of irregular bleeding and excessive hair growth.
- Insulin Resistance: Recently, it has been discovered that PCOS women have an abnormality of insulin secretion. Women with PCOS are more resistance to the action of insulin than normal women and, as a result, have a greater long-term risk of developing diabetes mellitus. Insulin resistance is associated with anovulation in PCOS as treatment with insulin sensitizing drugs has resulted in increased ovulation rates.
- Heart Disease: Another long-term concern i PCOS women is that of cardiovascular risk. Androgens are known to induce an unfavorable lipid profile by increasing low-density lipoprotein and triglycerides while decreasing high density lipoprotein. In addition, in overweight women, the presence of obesity independently worsens the lipid profile and only further increase this risk. Thus, the excessive production of androgen in PCOS, particularly in the presence of obesity, places these women at significant increased risk for heart disease.
| Menstrual Irregularities | Irregular periods are a nuisance and suggest some hormonal disorder or risk of endometrial thickening. Any irregular bleeding should be checked by a doctor who may prescribe hormonal treatments to regulate the menstrual cycle. | ||
| Hirsutism | Management of excessive hair growth includes suppression of ovarian androgen production by oral contraceptive medication ( birth control pills). In addition, there are drugs which may prevent the effects of androgens and include spironolactone, flutamide, and finasteride. These medications may be prescribed by your doctor. Electrolysis may also be effective. Local removal techniques provide only temporary relief. | ||
| Weight gain | In obese women, a program of careful weight reduction combined with a healthy life-style may promote improvement in the clinical manifestations of PCOS. Weight loss is associated with lowered androgen effects, less insulin resistance, an improved lipid profile, and resumption of ovulatory function. Even a small reduction in weight may have a beneficial impact. In addition, weight loss may also lower the long term risk of diabetes and heart disease. | ||
| Fertility Difficulty | In women with PCOS, failure to ovulate is the usual reason for not achieving pregnancy. However, prior to initiating fertility treatment, it is recommended that other factors which impact fertility should be evaluated. These factors include tubal patency, pelvic anatomic relationships, and assessment of semen and sperm function. | ||
If clomiphene fails to successfully induce ovulation, 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 activities, (hMG-human menopausal gonadotropin), while the other contains FSH only, (ie: Follistim AQ Cartridge follitropin beta injection). Although both types of gonadotropin work well in women with PCOS many programs prefer to use the products which contain primarily FSH. Initial therapy includes daily administration in small amounts with progressive increases in dose until ovulation is achieved. Follicular development and growth is carefully monitored by hormone measurements and ultrasound examinations. If monitoring shows that too many follicles are developing, and the risk of multiple pregnancy is high, then treatment will usually be suspended and ovulation induction in that cycle canceled. When development and growth of the follicle reaches optimum maturity, then human chorionic gonadotropin (hCG) is administered by injection to stimulate release of the egg from the follicle.
Women with PCOS given gonadotropin are at an increased risk of a rare but potentially serious condition known as Ovarian Hyperstimulation Syndrome (OHSS). In the early stages of the condition, ovaries become suddenly enlarged with an accumulation of fluid in the abdomen. Early signs of OHSS to be aware of include: pelvic pain, nausea, vomiting, weight gain and reduced urine production. In more severe cases, fluid may accumulate in the lungs, causing breathing difficulties. If an ovary ruptures, blood can also accumulate in the abdominal area. Other complications that may occur include severe fluid imbalances, which also cause blood clotting problems such as inflammation of veins, stroke, and pulmonary embolism.
On rare cases, complications from ovarian hyperstimulation syndrome, including blood clotting problems and/or bleeding difficulties, may be life threatening and could cause death. Some women, such as those with polycystic ovarian syndrome, run a higher risk of hyperstimulation and should be identified before treatment begins.
Careful monitoring and adjustments in the ovulation induction treatment regimen by the reproductive medicine specialist prior to ovulation may be markedly reduce (but not eliminate) the risk of OHSS.
Your physician will discuss risks and benefits of your treatment with you.
Recently, it has been shown that in women with PCOS, penetration of the ovarian capsule by multiple puncture results in resumption of regular ovulate function. This is usually preformed through a apparels and puncture may be achieved by either cattery or needle penetration at multiple sites. In some cases, regular ovulation persists for some time, whereas in other patients, after several spontaneous normal ovulations, irregular or absent menstrual function recurs.
The technique of IVF refers to the fertilization of a woman's egg with her partner's sperm in the laboratory. Following fertilization, the embryo is then placed in the woman's uterus in anticipation of implantation and pregnancy. This procedure is recommended to women who have blocked fallopian tubes, or men with poor quality sperm. IVF is also offered to women with PCOS who wish to conceive after other treatment strategies have failed. SInce a part of the protocol for IVF includes gonadotropin induction of ovulation, these patients must be carefully monitored in an effort to avoid Ovarian Hyperstimulation Syndrome.