Polycystic ovary syndrome (PCOS)
Definition of Polycystic ovary syndrome (PCOS)
Polycystic ovary syndrome (PCOS), also known as Stein-Leventhal syndrome, is a common hormonal disturbance that affects the glands responsible for hormone secretion, in particular, the pituitary gland (located at the base of the brain).
This condition particularly affects women of childbearing age (between 8% and 13% of them suffer from PCOS), and is characterised by an increase in male androgenic hormones (testosterone), which causes a range of symptoms with varying degrees of discomfort, including:
- hirsutism (excessive hair growth),
- alopecia (hair loss),
- and even infertility.
Causes of Polycystic ovary syndrome (PCOS)
The causes of this hormone imbalance are still poorly understood. To date, the main suspected risk factors are genetics, epigenetics and the environment:
- Genetics and epigenetics: between 60 and 70% of women born to mothers with PCOS develop the symptoms at one point of their lives. Studies also show that a woman's ethnic origin plays a role in the development of PCOS symptoms. In fact, according to one study, 60-80% of American women with PCOS suffer from hirsutism, compared with 20% of Japanese women with the same condition.
- Environment: endocrine disruptors, such as Bisphenol A, for example, are also thought to be playing a role in the onset of the disease.
Symptoms of Polycystic ovary syndrome (PCOS)
The symptoms of polycystic ovary syndrome (PCOS) generally appear at puberty, around the time of the first menstrual cycle, or even much later.
The intensity of these symptoms can vary considerably from person to person, ranging from mild discomfort to significant disability.
The most common symptoms include:
Ovarian cycle disorders
In the case of polycystic ovary syndrome (PCOS), the functioning of a woman's ovarian cycle is dysregulated, which can lead to heavy, long, irregular, unpredictable or non-existent periods (amenorrhoea). In addition, the ovaries do not release any eggs (anovulation), or release them irregularly, which can make it difficult to get pregnant (potential infertility).
Hyperandrogenism (overproduction of androgens)
In women of childbearing age, testosterone is the main androgen. It has three origins: around 25% of it comes from the adrenal glands, 25% from the ovaries and 50% through peripheral conversion of androstenedione (delta4A) into testosterone.
In the case of PCOS, an increase in ovarian androgens causes hyperandrogenism, which manifests itself as an excessive development of masculine characteristics in women, such as hyperpilosity or even hirsutism (abnormal hair growth), alopecia (hair loss) or persistent acne after the age of 20.
PCOS affects the metabolism, i.e. energy expenditure, the way in which our body uses and stores calories we ingest. This may result in hyperglycaemia (increased glucose levels in the blood) and/or dyslipidaemia (increased LDL cholesterol and/or triglycerides, and/or reduced HDL cholesterol levels in the blood). These two phenomena predispose patients to suffering from excess weight (or even obesity) and high blood pressure.
Other symptoms can also be associated with PCOS, but they are not common to every patient: for example, brown spots on the skin, fatigue, anxiety and sleep apnoea.
Diagnosis of Polycystic ovary syndrome (PCOS)
The diagnosis is generally made by a general practitioner, a gynaecologist or an endocrinologist. It is mainly based on the symptoms experienced by the patient, but also on blood tests and, sometimes, an abdomino-pelvic ultrasound.
The tests are designed to rule out other possible hormonal disturbances that can provoke similar symptoms, such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing's syndrome or hyperprolactinaemia.
This check-up includes:
- An FSH and LH assay: these two hormones produced by the pituitary gland control the ovarian cycle. FSH facilitates ovulation and encourages the development of follicles containing eggs. LH, on the other hand, causes ovulation, thanks to a peak in secretion in the middle of the ovarian cycle. Normally, the basal level of LH should be lower than that of FSH at the time of ovulation, and a rise in LH levels can be observed just before ovulation.
In PCOS, the basal LH level is higher than the FSH level and does not increase in the middle of the cycle.
- An assay of male sex hormones or androgens (testosterone, Delta4 androstenedione, SDHEA and 17 OH progesterone): the usual level of testosterone for women is between 0.3 and 3 nanomoles per litre of blood. In PCOS, this level is higher.
- Glucose and insulin levels: in PCOS, blood glucose and insulin levels are higher than normal.
- Other hormones levels may also be assessed, such as prolactin (which plays a role in reproduction and breastfeeding) or TSH (thyroid-stimulating hormone), a hormone that stimulates the thyroid gland.
In polycystic ovarian syndrome, FSH levels are insufficient for follicular maturation, leading to an accumulation of immature follicles in the ovary. This can be seen on abdomino-pelvic ultrasound, with the presence of numerous small follicles giving a "polycystic" appearance to the ovaries, which explains the name of the disease.
The impact of polycystic ovary syndrome (PCOS)
PCOS has a short- and long-term impact on the physical and mental health of the patients.
Thus, the disease can lengthen the average time it can take you to become pregnant. This factor, coupled with other symptoms such as hyperpilosity or hair loss, can lead to anxiety, depression or a negative self-image.
PCOS can also lead to long-term complications such as cardiovascular disease (myocardial infarction), diabetes and even endometrial cancer.
Treatment of polycystic ovary syndrome (PCOS)
PCOS is a chronic condition that cannot be cured. However, it is possible to improve certain symptoms by making lifestyle changes and taking medication.
Treatment options for polycystic ovary syndrome (PCOS)
Anti-androgen treatment helps reduce the symptoms caused by hyperandrogenism, in particular hirsutism, acne and hair loss.
Anti-androgenic treatment is usually presented in the form of an oral contraceptive pill containing oestrogen and progesterone.
Progesterone hormones inhibit the secretion of LH, thereby reducing the production of androgens (testosterone) by the ovaries. Oestrogenic hormones reduce the level of androgens circulating in the blood (free testosterone) by binding them.
- Taking the pill may cause high blood pressure or hyperlipidaemia. It is essential to talk to your doctor before taking any form of treatment.
- A combination of oestroprogestogenic hormones is also available in the form of a vaginal ring or transdermal patch.
If oestroprogestogenic contraception fails, the recommended treatment is cyproterone acetate. This is an anti-androgenic progestogen which lowers total testosterone levels by inhibiting LH, and inhibits the peripheral effects of androgens by blocking their binding to their receptors.
Acne can be treated with a local treatment (anti-acne cream), antibiotic therapy or isotretinoin. To treat alopecia, there are drugs available in pharmacies that stimulate hair growth and limit hair loss. As for hirsutism, there are a number of techniques that can be used to remove hair temporarily or even permanently, including depilatory creams and lasers.
Infertility treatment is based on stimulating ovulation with the help of:
- Clomiphene citrate: this drug plays a role in modulating and continuously releasing FSH to encourage follicle development.
- Injectable exogenous gonadotropins: these are injections of FSH hormones, necessary for follicular maturation and preparation of an oocyte for ovulation.
Other solutions can be considered if ovarian stimulation fails, such as invasive treatments.
Ovarian surgery or "drilling": it is a laparoscopic surgical technique that involves making micro-incisions in the superficial layer of the ovaries to facilitate spontaneous ovulation.
In vitro fertilisation, or IVF, is a technique whereby oocytes and sperm meet in the lab environment in order to induce fertilisation. This treatment is indicated when other medical conditions exist, such the fallopian tubes disorders (occlusion of the duct linking the ovary to the uterus), low sperm count, or when simpler procedures have been tried without positive results.
It consists of stimulating the growth of the follicles until they mature, recovering the oocytes, fertilising them with a spermatozoon in the laboratory, and then reintroducing the fertilised oocyte into a woman’s uterus.
Treatment of metabolic disorders
Metabolic abnormalities are first and foremost treated by lifestyle changes and dietary measures.
This means that patients need to adjust their diet and exercise. If you are overweight, losing around 10% of your initial weight reduces hyperandrogenism, and has a beneficial effect on amenorrhoea (absence of menstruation) and fertility.
It is recommended to eat a well-balanced diet (50% carbohydrates, 30% fats, 20% proteins).
In order to provide the body with as many vitamins and minerals as possible you can:
- have a diet rich in omega-3 (salmon, sardines), omega-6 (evening primrose oil, borage oil) and omega-9 (walnut oil),
- limit foods that can cause inflammation (sugar, alcohol, too much red meat, dairy products, gluten) and opt for foods with anti-inflammatory properties (fresh fruit, vegetables, wholegrain cereals, nuts),
- limit fast sugars and opt for foods with a medium or low glycaemic index (=GI), for example, try wholemeal pasta instead of white pasta.
Exercise can also help reduce symptoms of anxiety and depression and facilitate weight loss.
If changing your eating habits and doing more exercise does not help, your GP can prescribe you oral anti-diabetic drugs.
Published 30 Jan 2024