Polycystic Ovary Syndrome (PCOS): More than Polycystic Ovaries

Arguably one of the more well-known conditions that can affect fertility is Polycystic Ovary Syndrome, PCOS for short, which affects 10-15% of people with ovaries. However, evidence has shown that this number may actually be an underestimation, and PCOS is likely to be under-diagnosed.

PCOS represents a collection of features. These include (1) irregular or no periods (with either no ovulation or decreased frequency), (2) high androgen levels (a group of hormones traditionally associated with male sex, primarily testosterone – which can either be recognised through the associated symptoms or blood tests) and (3) polycystic ovaries. The most widely used criteria for diagnosing PCOS requires people to have 2 of these 3 groups of features to be diagnosed.

Contrary to what the name suggests, polycystic ovaries alone do not automatically mean PCOS. Conversely, polycystic ovaries do not have to be present for someone to have PCOS.

PCOS affects people in a wide variety of ways. As mentioned previously, it can affect fertility, menstrual cycles, as well as hormones. These hormonal changes can cause hirsutism, which results in acne and excess growth of dark, coarse hair in a stereotypically male-like pattern. This occurs on the face (namely chin and upper lip), chest, back and abdomen. Importantly, PCOS is a risk factor for endometrial cancer.

Perhaps less commonly known are the more widespread implications of PCOS. The effects of PCOS extend beyond hormones and the reproductive system. PCOS is also associated with obesity, and people with PCOS are more likely to have type 2 diabetes, high cholesterol levels, high blood pressure, and heart problems.

What can we do?

Unfortunately, PCOS is one of those conditions where there is no ‘cure’. It is a lifelong condition, but the different aspects of it can be managed.

As with most aspects of your health, lifestyle factors are very important. This includes taking steps to maintain a healthy weight, for example through diet and exercise. By keeping your BMI in a healthy range, you can decrease your chances of the widespread implications mentioned above – including endometrial cancer. Of course, there are more factors at play than just diet and exercise. Your doctors will always be happy to discuss weight loss with you and present the options through which they can help.

Whilst no one can deny that lifestyle and weight management is important, sometimes the aspects of PCOS that affect your life most are the ones you can see, like the effects of hirsutism. Luckily, maintaining a healthy weight helps to control this from the inside out. From the outside – physical hair removal treatments include electrolysis, waxing, bleaching and hair removal creams. More long-term methods include laser treatment and photothermolysis. Topical treatments can also be prescribed. Eflornithine targets hair growth at the level of the hair follicle. It can be used in isolation or together with hormonal contraception. Hormonal contraception is also used for acne that can be associated with PCOS.

As we have already seen, hormonal contraception is a bit of a multitasker. This extends to people with PCOS who are struggling with their periods – whether that be heavy periods, no periods at all or cycles that are irregular and have no particular pattern. For a lot of patients, hormonal medication is used in the form of the combined oral contraceptive pill (COCP), more commonly known as ‘the pill’. It provides regularity via withdrawal bleeds. A withdrawal bleed is a term used for bleeding that people on the COCP experience. It is an artificial bleed, in that it is not caused by ovulation. Rather, it is caused by a dip in hormone levels during pill-free breaks. Withdrawal bleeds also help to decrease the risk of endometrial cancer, as they still shed the lining of the uterus. Other options include ‘the hormonal coil’, an Intrauterine System (IUS) that contains progesterone.

Shedding the lining regularly, at least every 3 months, is very important for people with PCOS. If your periods are less regular than this and you don’t want to take the COCP – another option available to you is inducing bleeds as and when they are needed. This would involve monitoring the thickness of the endometrial lining with ultrasound scans.

What about Fertility?

PCOS accounts for around 80-90% of people with anovulatory infertility, which literally means infertility caused by a lack of ovulation. Lifestyle factors are, again, very important. A BMI of less than 30 is ideal for ovulation, and also helps to reduce risks in the subsequent pregnancy.

A number of methods (e.g. clomifene citrate, gonadotrophin therapy, surgical ovulation induction) to induce ovulation are used. However, they are not without risks. These include ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. OHSS occurs when too many follicles are stimulated and can lead to fluid build-up in the abdomen, lungs and sometimes even around the heart. This is a rare but potentially life-threatening complication. In order to reduce these risks as much as possible, measures are put in place; ranging from careful monitoring with ultrasound scans, to following strict criteria to limit the numbers of follicles ovulating.

Clomifene citrate or letrozole is the first-line options. Either medicine is given at the start of the menstrual cycle, when the person is bleeding, for 5 days. When Clomifene fails, other options for ovulation induction include gonadotrophin therapy or surgery.

Gonadotrophin therapy is given as a subcutaneous injection, just under the skin. Much like how the COCP mimics the body’s natural hormones, oestrogen and progesterone, gonadotrophin therapy does a similar thing by stimulating the ovaries to work.

Surgical ovulation induction is an alternative to gonadotrophin therapy. Laparoscopic ovarian diathermy, also known as ‘ovarian drilling’, is a surgical method used to restore ovarian activity. Surgical methods do not carry the same risk of multiple pregnancy and OHSS, as it does not use hormones. However, all surgery involves risks.

If measures to induce ovulation have failed after a period of time, it is unlikely that anovulation is the reason for your difficulty conceiving. We can therefore try assisted conception, usually IVF.

What about pregnancy itself?

Those with PCOS who are expecting have higher risk pregnancies than people without PCOS. This includes the risk of gestational diabetes, high blood pressure, pre-eclampsia, preterm birth and other neonatal complications. Your midwife and obstetrician will take measures to reduce these risks and ensure the safety of you and your baby. This can include more frequent monitoring, testing for diabetes before and/or during pregnancy, and more.

Take home message

PCOS is more common than we think, and it affects many aspects of your health. Fortunately, there are many things we can do to target those areas and help your physical, mental and reproductive health.