Polycystic Ovary Syndrome: Facts and Treatments

by Walter Futterweit, MD, FACP

What is Polycystic Ovary Syndrome?

Polycystic ovary syndrome (PCOS) is the most common endocrine problem in women, affecting 5 to 7.5 percent of reproductive-aged women, yet it is only in the past decade that ideas about its causes and treatment are being pieced together. Although what causes it remains unclear, the main cornerstones of diagnosis and treatment are well established. While the syndrome has a wide spectrum of clinical presentations, in most cases it causes the ovaries to become enlarged with multiple small cysts. This condition eventually results in the secretion of excess androgens, mostly testosterone. The endocrine abnormality is marked by erratic menstrual cycles and infertility. The excess androgens also exert effects on the hair follicles and sweat gland unit of the skin (pilosebaceous unit), often leading to acne, excessive facial and body hair growth (hirsutism), and thinning of scalp hair (alopecia).

Many of the latter features are variable, and the characteristics of the classical symptom complex described above may occur either singly or in combination. For example, menstrual abnormalities may occur early at puberty and vary over time, while other women present with persistent acne even in their 30s in association with abnormal menstrual cycles. Obesity is present in about 50 to 60 percent of patients and there is a frequent tendency for fat to take on a central distribution (apple-shaped, rather than pear-shaped obesity). The resulting increase in the so-called waist-to-hip ratio (WHR) is a marker that often indicates the potential for metabolic or cardiovascular complications.

Characteristics of PCOS

The cause of polycystic ovary syndrome is still unclear, but several characteristics are now firmly established:

• There is a strong genetic component to the syndrome and several cases of PCOS in the same family is commonplace.
• There is an association between PCOS and increased blood levels of insulin (hyperinsulinemia), which is amplified by obesity. The increased blood levels of insulin cause a number of effects, some of which may lead to glucose intolerance or frank type 2 diabetes mellitus.
• Normal ovarian function relies on the selection of a follicle in the ovary, which is largely a response to an appropriate signal from substances called follicle-stimulating hormone and luteinizing hormone-two hormones secreted by the pituitary gland. In PCOS, there's a hypersecretion of pituitary luteinizing hormone (LH) and the high levels of both LH and insulin appear to stimulate the ovary to produce excessive male hormones (androgens). Obesity magnifies this effect.
• Intrinsic enzymatic abnormalities have been demonstrated in the ovaries as well as the adrenal glands, which are a significant factor in the syndrome.
• The higher centers in the brain may be implicated in the characteristics of the disease. Both hypothalamic and pituitary dysfunction have been reported (e.g., Abnormal hypothalamic stimulation to the pituitary gland leads to increased pulses of luteinizing hormone).

The frequent presence of insulin resistance (IR) may be at times selective, (i.e., lean or normal-weight women who tend to have more regular cycles tend to be less likely to have insulin resistance) so that not all patients demonstrate the major consequences of hyperinsulinemia.

Diagnosis of Polycystic Ovary Syndrome

It should be noted that polycystic ovary syndrome is a syndrome, not a disease, and authorities have differed on the definition of the entity. The classic findings that most doctors agree on include the following: