Polycystic Ovary Syndrome: A Review

 

Polycystic Ovary Syndrome Awareness Month

 

September 6, 2021

By Jeremy Lickteig, MD

Polycystic Ovary Syndrome: A Review

Editor’s Note: September is designated as Polycystic Ovary Syndrome (PCOS) Awareness Month, and FACTS will raise awareness of this common condition with a variety of research reviews and interviews with physicians and patients. We begin the series with this thorough summary of a 2018 article titled, “Polycystic Ovary Syndrome”[i] that was published in Obstetrics and Gynecology by Dr. Ricardo Azziz. Dr. Jeremy Lickteig summarized the article below, and then discusses how fertility awareness-based methods (FABMs) can help identify and manage root causes of PCOS to aid in restoring fertility for these patients.

What is PCOS?

Polycystic Ovary Syndrome is an important condition that all medical professionals who care for women should understand. It is not benign. Infertility, acne, irregular cycles, insulin resistance, and excess body hair are some of the most common features of PCOS. It is estimated that between 5 and 20% of women suffer from it. Despite this, more than 30% of women report greater than two years, and contact with three or more health professionals before a diagnosis of PCOS is made.i

PCOS is the “single most common endocrine-metabolic disorder in reproductive-aged women.”i Because of the complex nature of endocrine disorders, there are several potential features of PCOS. While the presentation may differ among women, there are three main clinical findings: hyperandrogenism, oligo-anovulatory cycles, and polycystic ovaries. Per the Rotterdam criteria, two of these findings are required to make a diagnosis of PCOS.

Clinical hyperandrogenism can take the form of excess male pattern terminal hair growth (also known as hirsutism), acne, and/or alopecia. Hyperandrogenism can also be diagnosed with “one abnormal androgen value,” such as elevated testosterone or DHEA-S.i

Abnormal, frequently anovulatory, cycles are another mainstay of PCOS presentation. Oligo-anovulation refers to cycles longer than 35 days, which means these women have less than 8-10 cycles per year. Some women present with more frequent menstrual bleeding days each cycle.

The final diagnostic criterion is the presence of polycystic ovarian morphology. Ultrasound is most useful as a diagnostic tool after a patient has been off of hormonal suppression, such as oral contraceptives (OCPs), for at least 6 months. This criterion is less useful in adolescents.

Potential Consequences of PCOS

Polycystic ovary syndrome can have significant consequences if left untreated. The effects of hyperandrogenism may decrease a woman’s quality of life, and the cycle abnormalities may lead to subfertility or infertility. Obesity is another factor in PCOS that impacts quality of life. Patients who present with PCOS are more likely to be obese, but the actual difference in weight between matched populations without PCOS may not be significant, at least in the United States.

When patients are matched to the rest of the population for factors including obesity and age, women with PCOS are significantly more likely to have diabetes mellitus. Both insulin resistance and decreased insulin production are believed to contribute to this. The significant predisposition to diabetes also increases the risk for metabolic syndrome, which brings about its own potential (albeit poorly researched) risks, including cardiovascular disease and non-alcoholic fatty liver disease.

Separate from metabolic syndrome, women with PCOS are at greater risk for hypertension. Furthermore, when women with PCOS are able to achieve pregnancy, they are at increased risk for gestational diabetes, macrosomia, and pregnancy-related hypertension.

Evaluation

The diagnosis of PCOS must be confirmed using the Rotterdam criteria and by exclusion of other diseases. A thorough physical examination should be done to identify abnormal hair growth, acne, obesity, and signs of virilization. Additionally, the thyroid gland should be inspected. A transvaginal ultrasound can be used to assess for polycystic ovarian morphology to establish the diagnosis, and to evaluate the ovaries and endometrial thickness after diagnosis. Yet, ultrasound is not necessary for diagnosis if the other Rotterdam criteria have been satisfied.

Hormone testing has value in diagnosis and to establish a treatment plan. Progesterone can be measured on days 22-24 of the cycle to verify ovulation or to evaluate anovulatory cycles, but this may be less accurate. In women who are able to track their cycles and signs of fertility, a more targeted approach can use post-peak days to measure progesterone. The evaluation may also include anti-Müllerian hormone (AMH), a thyroid panel, prolactin, follicular 17-hydroxyprogesterone (17-OH progesterone), 24-hour urine free cortisol, testosterone, DHEA-S, LH, and FSH.[ii]

If the patient is using hormonal contraception or therapy, it is recommended that hormone levels be measured once off the medication for at least six months. An elevated AMH suggests increased preantral follicles, and elevated 17-OH progesterone suggests nonclassic adrenal insufficiency, the most common autosomal-recessive disorder. Cortisol testing is useful to rule out Cushing’s, as many patients may share similar clinical presentations.

In women diagnosed with PCOS, testing should be pursued to assess for comorbidities. A 2-hour, 75g fasting oral glucose tolerance test (OGTT) is recommended to rule out diabetes and measure insulin resistance. Hemoglobin A1C is not a reliable marker in PCOS. A lipid panel and liver function tests should be assessed at diagnosis in all patients, with an oral GTT and lipids repeated every 2-3 years.i

Furthermore, these patients should all be screened for anxiety and depression given the adverse effects of PCOS symptoms on quality of life. 

Treatment Principles 

The goals of PCOS management include decreasing androgen levels and activity, regulating menstrual cycles, thereby protecting the endometrium, addressing metabolic concerns, and improving fertility. For women not desiring pregnancy, the traditional first-line therapy is combination OCPs. These serve to produce a regular withdrawal bleed and protect the endometrium from unfettered proliferation associated with anovulatory cycles. They also “suppress gonadotropin secretion and ovarian androgen production.”i

Patients desiring fertility or treatments other than hormonal contraception may use cyclic bioidentical progesterone during the luteal phase, which is available PO, PV, or IM. This serves to regulate cycles and, thus, prevent endometrial overgrowth. Patients can also use metformin or another insulin sensitizer to decrease circulating androgens secondary to the complex endocrine-metabolic nature of this syndrome.

Regardless of the primary treatment method, patients must attempt to decrease androgens through weight loss.[iii] Practitioners can suggest a low carbohydrate or anti-inflammatory diet, caloric restriction, and increased activity to accomplish this. Other methods to address hyperandrogenism include spironolactone and flutamide. Patients with very resistant hyperandrogenism may need to consider using gonadotropin-releasing agonists.

While treatment of the underlying pathology will help fertility, ovulation induction with clomiphene or letrozole (off label) may be pursued in some patients. Failure of these methods often leads to a recommendation of ovarian drilling, wedge resection, or in-vitro fertilization (IVF) with embryo transfer.

Fertility Awareness in PCOS

A growing number of physicians report success using cycle charting and fertility awareness-based methods to cooperate with medical therapy and a woman’s physiology. By using temperature, hormone test strips, and/or cervical mucus models, women can identify whether or not their cycles are truly within normal limits. This proves to be valuable information, as 40% of women with hirsutism who claim to be eumenorrheic are actually oligo-anovulatory. Cycle tracking can also identify the follicular and luteal phase accurately, so one can ideally use or measure progesterone on specific post-ovulatory luteal days, as opposed to numbered cycle days in women who do not use FABMs.

Unlike other treatment methods, FABMs used cooperatively with medical management allow a woman to simultaneously delay pregnancy and treat her symptoms while her fertility is restored. While OCPs may provide symptomatic relief, they are not without side effects and do not work to restore fertility, so a woman can expect to see her symptoms return upon discontinuation of OCPs.

Editor’s Note: FABMs offer an alternative that does not suppress but cooperates with a woman’s physiology, and aids in identifying root causes of abnormalities to understand, treat, and restore both fertility and overall health. To learn more about PCOS diagnosis, treatment, and FABM applications in this common condition, please follow the links below.

 

References

[i] Azziz R. (2018). Polycystic Ovary Syndrome. Obstetrics and gynecology, 132(2), 321–336. https://doi.org/10.1097/AOG.0000000000002698.

[ii] Gibson-Helm, M., Teede, H., Dunaif, A., & Dokras, A. (2017). Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome. The Journal of clinical endocrinology and metabolism, 102(2), 604–612. https://doi.org/10.1210/jc.2016-2963.

[iii] Sheehan M. T. (2004). Polycystic ovarian syndrome: diagnosis and management. Clinical medicine & research, 2(1), 13–27. https://doi.org/10.3121/cmr.2.1.13.

[iv] Dokras, A., Sarwer, D. B., Allison, K. C., Milman, L., Kris-Etherton, P. M., Kunselman, A. R., Stetter, C. M., Williams, N. I., Gnatuk, C. L., Estes, S. J., Fleming, J., Coutifaris, C., & Legro, R. S. (2016). Weight Loss and Lowering Androgens Predict Improvements in Health-Related Quality of Life in Women With PCOS. The Journal of clinical endocrinology and metabolism, 101(8), 2966–2974. https://doi.org/10.1210/jc.2016-1896.

About the Author

Jeremy Lickteig, MD 

Jeremy Lickteig, MD is a family medicine resident at Ascension Via Christi in Wichita, KS. He wrote this review as a fourth-year medical student while on the FACTS fertility awareness elective. Dr. Lickteig attended Washburn University and the University of Kansas School of Medicine-Wichita. He plans to practice in rural Kansas with special interests in obstetrics and caesarean sections, women’s health, and sports medicine.

Pin It on Pinterest