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The polycystic ovary syndrome (PCOS) is one of the possible causes a woman may not get pregnant as quickly as she planned. However in this situation effective treatment to increase the chance of pregnancy is available.
A woman with this syndrome usually has a large number of small cysts in her ovaries, plus some or all of the features described below. About one in five (20%) of all premenopausal women have polycystic ovaries, however, not all of these women have the polycystic ovary syndrome.
Many women do not know they have polycystic ovaries. Polycystic ovaries are most easily seen by an ultrasound scan. They contain many small cysts usually no bigger than 8mm in diameter. Some of these cysts contain eggs. These small cysts usually do not get any bigger; with time they disappear, only to be replaced by other small cysts. They do not need to be removed by surgery. In the normal function of an ovary one of these cysts (also called follicles) grows to about 20mm in diameter before it releases an egg. Only very large cysts – more than 50mm in diameter – need to be removed.
The cause of polycystic ovaries and of the polycystic ovary syndrome is not entirely clear. In part, they may be inherited and therefore are likely also to be present in women of the same family. Ovaries do not suddenly become polycystic; however, women who have always had polycystic ovaries may develop symptoms at any time. There is a connection between having polycystic ovaries and a genetically determined partial resistance to the action of the hormone insulin. This resistance becomes more severe in association with weight gain, a sedentary lifestyle, pregnancy and the use of a number of drugs, particularly cortisone. Any of these factors may mean a woman with polycystic ovaries develops other features of the polycystic ovary syndrome, as described below.
Menstrual periods may be irregular, heavier than usual or prolonged, occur after long time intervals, or in some women not at all. This is because ovulation may not occur regularly.
Instead of ovulating once each month, a woman with the polycystic ovary syndrome may ovulate irregularly, usually not every month. This means, without treatment, these women do not have as many chances each year to become pregnant. However, it is important to know that many women with the polycystic ovary syndrome become pregnant without treatment and may never know they have the syndrome. Polycystic ovaries do not regularly respond to the quantity of stimulating hormones normally produced by the pituitary gland. However, they usually respond to additional amounts of these hormones given as treatment.
The polycystic ovary syndrome is is one of the conditions associated with an increase in the risk of miscarriage. The risk of miscarriage increases with increased body weight.
The blood level of the male hormone, testosterone may be higher in women with the polycystic ovary syndrome than in other women and this causes acne, greasy skin and unwanted hair growth on the face, chest and abdomen. The blood levels of testosterone in women with the polycystic ovary syndrome are still much lower than the levels found in men.
Weight gain is common in women with the polycystic ovary syndrome. However, not all such women are overweight. Some women with polycystic ovaries only develop symptoms of the syndrome when they gain weight. Therefore, maintaining a normal body weight reduces the risk of developing the syndrome as well as reducing the risk of diabetes, heart disease and arthritis later in life.
Cancer: Ordinarily, a woman with this syndrome does not have an increased risk of cancer of the ovaries. It has been suggested that repeated treatment to stimulate the ovaries in any woman may very slightly increase the risk of ovarian cancer.
Women who have irregular periods may have a slightly increased risk of developing cancer of the endometrium. Regular shedding of the endometrium by having regular periods helps to prevent endometrial cancer. If the endometrium appears thick on an ultrasound scan, or if very irregular, prolonged bleeding occurs, a curettage (tissue removal) might be advised.
Diabetes: Women with the polycystic ovary syndrome have an increased risk of developing diabetes. This risk is greater if they have irregular periods, are overweight and/or have a family history of diabetes. The risk also increases with age. These women also have an increased risk of developing diabetes during a pregnancy (gestational diabetes), which if not recognised quickly and treated carefully has an adverse effect on the baby.
This syndrome should not be regarded as a disease. It is a characteristic of the body of some women and cannot be permanently ‘cured’. However, the symptoms described above may be controlled with medical treatment. All women with polycystic ovaries should try to maintain a normal weight and a good level of physical fitness.
For women who have no wish to become pregnant, menstrual periods may be controlled by a low dose contraceptive pill. Women who cannot take the pill should try a progesterone-only treatment (eg. Provera or Primolut N) for 12 days each month. Any persistent irregular bleeding should be checked by a doctor, who may advise an ultrasound scan or occasionally a curettage (tissue removal). A pap smear should be taken at least once every two years.
This is most likely due to lack of regular ovulation in women with polycystic ovaries. However, you should remember other unrelated causes of infertility such as blocked fallopian tubes, or a partner with a low sperm count, may be present.
When ovulation is irregular or not occurring at all, drug or hormone treatment may be required. The most common drug treatments are clomiphene citrate (Clomid or Serophene) or letrozole (Femara), which are taken as a tablet for five days, early in the cycle. Clomiphene can cause a reduction of mucus in the cervix and this may prevent the passage of sperm through the cervix. Therefore, although clomiphene may cause ovulation, pregnancy will not always occur.
A few women experience side effects with clomiphene including bloating, headache, stomach upset, breast discomfort, dizziness and depression. The risk of a multiple pregnancy is slightly increased by the use of these drugs. There is no increase in the risk of birth defects from these drugs.
If pregnancy does not happen after clomiphene or letrozole, hormone injections may be used. The hormones used, FSH and LH, are called gonadotrophins. They are normally produced by the pituitary gland and can be synthesized in the laboratory. Gonadotrophins extracted from human pituitary glands are NOT used. FSH is mainly responsible for stimulating the growth or follicles and LH stimulates release of the egg from the follicle.
Polycystic ovaries are usually very sensitive to stimulation by these hormones and commonly more than one follicle will grow when the injections are given. Because of this treatment begins with low doses and the response is carefully monitored by blood tests and ultrasound scans. If monitoring shows that too many follicles are developing there is a high risk of multiple pregnancy. If this occurs the injections will be stopped and contraceptive measures must be used for several days.
Women with polycystic ovaries given gonadotrophins are at an increased risk of a serious, uncommon condition called the ovarian hyperstimulation syndrome (OHSS). This condition occurs if too many follicles are stimulated, resulting in abdominal swelling and nausea. Monitoring is essential to avoid this situation.
When other treatments have not been successful in causing a pregnancy, In vitro fertilisation (IVF) may be offered to women with the polycystic ovary syndrome. This treatment involves collecting eggs from a women’s ovaries (usually after she has been given gonadotrophin injections), then fertilising them with her partner’s sperm, in the laboratory. IVF carries a risk of ovarian hyperstimulation syndrome and therefore a woman having this treatment must be carefully monitored.
Acne and unwanted body hair may be reduced by taking a combination of tablets. Oestrogen (as found in the oral contraceptive pill) is combined with an antiandrogen tablet (usually spironolactone or cyproterone acetate) and the combination must be taken for many months to obtain some benefit. This therapy is contraceptive and cannot be used when trying to conceive. Waxing, electrolysis or laser may be used to remove unwanted hair while waiting for the hormone treatment to work. However, these cosmetic treatments should be performed by a trained therapist as scarring can result from unskilled treatment. If the skin problem is related to the polycystic ovary syndrome, hormonal treatment is the logical solution.