In Madame Tussauds Wax museum in London in 1964 I saw a pair of wax figures of an elderly man and a women with long beards , somewhat obese and a child of about five years old standing in between them. This tells the major story of PCOS, obesity, hairiness(hirsutism) and infertility.
PCOS was first described in 1935 by two physicians Stein and Leventhal and therefore in days gone by it was often called Stein-Leventhal Syndrome.
In those days it was very rare and in my five years at medical school I saw about five cases. Now in my retirement fifty years later, I was seeing almost ten cases a week.
There is actually no international agreement as to what it should be called, but for the time being we have agreed to call it Polycystic Ovarian Syndrome all this is mainly due to failure of ovulation. This confusion is because there are many complex signs and symptoms of the disease and it is difficult to justify them by one explanation.
The main symptoms are irregular periods, obesity, hirsutism, hormone disturbances and polycystic ovaries. These women also suffer from infertility. If a women has no polycystic ovaries on ultrasound she could still be suffering from PCOS. The National Health Service in the United Kingdom estimates that one in five women has polycystic ovary on ultrasound but has no symptoms.
They are just labelled as Polycystic Ovaries.
PCOS is often referred to as a "Silent Killer" because the diagnosis is difficult and if left undiagnosed in women they develop massive obesity, insulin resistance, Type2 Diabetes, high cholesterol, heart disease, sleep apnoea, metabolic syndrome, gestational diabetes, increased risk of uterine and breast cancer.
PCOS the ovarian function is very disturbed because they do not produce hormones to trigger ovulation. The growth of the growing egg(The Follicle)stops in the middle and little cysts remain in the ovary filled with fluid and as a result they produce an excess of male hormones called androgens(Testosterone).There is an excess of oestrogens as well.
The ovary grows in size causing pain and failure to ovulate as a result the menstrual cycle stops.
Increase in testosterone causes hirsutism and also can result in a male type of baldness.
The diagnosis is usually made by symptoms of irregular periods, hairiness, acne, obesity and infertility. The investigations that are relevant are polycystic appearance of the ovary, and altered hormone studies.
Most experts around the world are not sure what causes PCOS however most feel that altered hormone levels probably play a key role along with Insulin Resistance and Obesity.
With insulin resistance they produce to much testosterone and this stops the development of the egg and with insulin resistance they become obese which makes PCOS worse.
In my personal experience I have found PCOS common in young girls who were obese and their parents had diabetes.
Diagnosing Polycystic Ovarian Syndrome includes:
1- Hormone Levels
2- Ultrasound Size of the Ovary and the number of follicles on the ovary
3-Test to exclude Diabetes
4-High Cholesterol levels
5-Thyroid Function
6-Prolactin is rarely raised causing irregular period
7-Rule out other causes such as pituitary and adrenal diseases
Management of PCOS
There is no definitive cure for PCOS, we only treat the symptoms.
This depends on the patients age and the main problems. It is best to have a multi specialist consultation including gynaecologist, endocrinologist, dietician, physiotherapist, psychologist, infertility expert and a dermatologist.
Treatment Options of PCOS
1-Multispeciality Consultation
2-Life style factors must be altered, this helps not only PCOS but also insulin resistance, metabolic syndrome and risk factors such as Type2 Diabetes, high cholesterol and so on.
3-Weight Loss, Weight Loss, Weight Loss cannot be over emphasised.
4-Exercise within your tolerance and capabilities. Ideally 150 minutes a week.
5-Contraceptive pills in younger women are useful, many of these newer pills contain anti-androgen hormones which helps with the acne and hairiness. Please discuss these with your doctor as some of these have a slightly increased risk of deep vein thrombosis.
6-There are anti-hormone medications that you can buy individually that act against testosterone. These take a few months to show the benefits.
7-Metformin(Glucophage) has a beneficial affect on your general health caused by insulin resistance. There are many other drugs in this group they are called Glitazone, but in Australia Metformin is commonly used. A combination of these drugs is also thought to be helpful.
8-Patient suffering from infertility in addition to lifestyle and weight loss need other drugs such as Clomiphene which is often used in conjunction with Metformin.
9-If Clomiphene fails to produce ovulation then we use special drugs called Gonadotrophins. These drugs increase risk of multiple pregnancies. Recent researchers have shown that a new drug called Letrozole works better, it has less side effects and the risk of multiple pregnancies is less.
10-Surgical treatment this consists of diathermy of the ovary and this helps with ovulation. If the Clomiphene has failed it works after the drilling of the ovary.
11-You require a curettage if you are having unexplained bleeding from the uterus this will tell us the cause of bleeding and what to do next.
12-Bariatric surgery of various types(Surgery to lose weight) is very useful, this should not be taken lightly as it has many complications and is very expensive. The simplest of this is gastric banding.
In conclusion PCOS is a manageable problem do not neglect it, if you look after yourself you will be happy and healthy. A long time ago when laparoscopy, ultrasounds and drilling of the ovaries was not available the surgeons performed what was called a wedge resection of the ovaries, this helped in a few cases of infertility. It suggests to me that the removal of the thick stromal tissue decreased excessive secretion of the hormone called luteinizing hormone and this helps ovulation.
As there is no definitive treatment for PCOS some of the researchers are trying to see if we can prevent it. Towards this a group of young girls aged between 8 and 12 suggesting signs of PCOS were given Metformin, they were restudied at 18 years of age, in the treated group there were only 5 percent who developed PCOS, whereas, in the untreated group 50 percent developed PCOS.
Hopefully after further study this may provide prevention of PCOS in some girls.
Follow the lifestyle factors, of losing weight, exercise, correct diet and see if you can live without the PCOS and the whole mess of endocrine problems that you have. It is just not the ovaries. We have not yet succeeded in untangling the whole complex web of these problems.
