What do we mean by polycystic ovaries and how common is their appearance in the female population?
By polycystic ovaries, we describe those ovaries that contain many small cysts, which usually do not exceed 8 millimeters in size and which are most often located just beneath the surface of the ovary. These small cysts are follicles that contain eggs, but due to hormonal disorders and follicles they have not developed fully, exhibiting stagnation in their course of progression. Polycystic ovaries are common and occur in about 20-30% of women.
Polycystic ovary syndrome (PCOS) is a set of heterogeneous elements that cover a wide range of clinical manifestations, from the milder, such as menstrual cycle disorders, to the more serious, such as the risk of developing type 2 diabetes. Early symptoms usually occur in puberty, although in many women the symptoms may appear later in life. It is a common disorder that occurs in 10-15% of women.
- Unstable menstruation or amenorrhea
- Increase of hair growth (face, chest, stomach, back)
- Greasy skin and acne
- Increased weight or obesity, usually fat accumulation in the abdomen
- Type 2 diabetes
- High cholesterol
- Arterial hypertension
- Male pattern hair loss
- Vaginal spotting
- Snoring and sleep apnea
We usually find one or two of these symptoms, in a different severity, in women with polycystic ovary syndrome. We rarely find more than two and almost never all of them together.
The causes of polycystic ovary syndrome are not fully understood. It is the result of both genetic predisposition and the impact of environmental factors. In particular, there are indications that disturbances in the levels of a hormone secreted by the pituitary gland (LH-luteinizing) and high levels of androgens affect the smooth functioning of the ovaries. As a result, in the course of every menstrual cycle, the follicle does not develop enough to lead to ovulation but instead results in many small immature follicles that look like vesicles, so we use the term polycystic ovary. These small follicles cannot produce the necessary estrogens to induce ovulation, and this eventually leads to large delays in the menstrual cycle (irregular or missed periods). Also, androgens such as testosterone, androstenedione and dehydroepiandrosterone, which are typically produced by the ovaries and adrenal glands, in PCOS, are elevated mainly due to high levels of LH but also due to high levels of insulin.
Signs and symptoms usually begin during puberty, although some women do not show symptoms until they reach adulthood. Since hormonal changes differ from one woman to another, the severity of acne, hair growth and menstrual disorders is also different. Women usually have less than six to eight periods per year, while some have normal menstruation during adolescence, but this is later disrupted when the woman gains weight.
It should be noted that in about half of the cases, the syndrome is associated with gradual weight gain and obesity. Increased hair growth is mainly found in the face, the chest, on the upper surface of the abdomen and on the inner surface of the thighs and it often coexists with acne and oily skin.
As mentioned above, the syndrome is associated with elevated levels of insulin in the blood (insulin is a hormone produced in the pancreas and regulates blood glucose levels). When a person requires higher levels of insulin to maintain normal glucose levels, we consider this person to be insulin resistant. Both normal weight and overweight PCOS women show resistance to insulin and hyperinsulinemia, which are associated with unsatisfactory blood glucose regulation or even diabetes mellitus. Thus, 10% of obese women with polycystic ovary syndrome develop type 2 diabetes. In addition, women who are obese and also have insulin resistance or diabetes present an increased risk of coronary artery disease, whereas 30% of women with PCOS develop sleep apnea.
There is no single test that confirms the syndrome. A complete medical history, a gynecological examination, a gynecological ultrasound, a hormonal profile, as well as a glucose and insulin tolerance test should be performed. At the same time, any other cause associated with elevated androgen levels, such as congenital adrenal hyperplasia, androgen-secretory tumors and hyperprolactinaemia, should be excluded.
The diagnosis is finally set by the results of all the above tests. A physical examination will evaluate hair growth, so we recommend to avoid depilation a few days before the visit. During the gynecological check, the ovaries are often found to be increased in size due to the many small cysts inside them. This can be seen more easily with an ultrasound and ovarian volume measurements. During ultrasound a common finding is the numerous small bladders attached around the ovary. We also usually find a thick endometrium (inner lining of the uterus) due to irregular menstruation, as well as the presence of endometrial polyps (as a result of hyperestrogenaemia).
In regards to the presence of cysts in the ovaries, these do not cause problems, require surgical removal, or risk developing into cancer. In women who go for long periods of time without menstruating, and estrogen activity is continued without the protection of progesterone, ultrasound assessment of the endometrium is necessary as the risk of developing malignancies increases. To these women, a prophylactic hormonal treatment is recommended from the early stages, which not only stabilizes their cycle but also eliminates the risk of malignant mutation of the endometrium. Women with polycystic ovary syndrome and insulin resistance are at increased risk for developing diabetes mellitus, which is more likely to occur in overweight women. Also, these women are at increased risk for cardiovascular disease in the future.
There seems to be:
- High first trimester miscarriage rate.
- Higher rates of gestational diabetes.
Increased chances of premature delivery.
Initially, weight loss for overweight women is considered to be the most important goal. Weight loss helps to significantly restore hormone levels and improve the woman’s cycle. At the same time, proper nutrition and regular exercise significantly help reduce insulin levels in the blood. Combining the right body weight with a balanced diet reduces the risk of developing diabetes mellitus and cardiovascular disease in the future.
Adjustment of the menstrual cycle is achieved by hormonal therapy, the most common form of which is the contraceptive pill. Such treatment is carried out through follow-ups by the attending physician, so as to ensure proper medication for the patient. Hormonal therapy for cycle regulation is often combined with hormonal therapy to treat increased hair growth in the form of a dual action drug.
The most common fertility problem faced by women with polycystic ovary syndrome is ovulation disorder. The treatment of this disorder is mainly done with pharmaceutical agents, of which the most commonly used is clomiphene and the most modern treatment with aromatase inhibitors (Femara). Treatment with the above formulations induces ovulation in 75% of patients. Women who do not have ovulation after treatment with anti-estrogens can undergo injectable gonadotropin hormone therapy. Alternatively, ovulation can be induced after ovarian drilling, a surgical procedure that is performed laparoscopically with very good results. Finally, if all of the above options do not succeed, the couple can follow the IVF process.
Contraceptive tablets in combination with antiandrogens are administered for treating acne and oily skin.
It should be stressed that in women with amenorrhea, the continuous action of estrogens caused by polycystic ovary syndrome may have an adverse effect on the uterus and the breast (rarely developing malignancy). Therefore, administering low-dose contraceptive pills is a treatment of choice for women who do not wish to get pregnant.