Polycystic Ovarian Syndrome Symptoms
To make a diagnosis of PCOS there are a set of criteria called the Rotterdam criteria.
A patient needs any two of the following:
- Evidence of ovulation problems
- Evidence of male hormone excess
- Ultrasound evidence of polycystic ovaries.
Ovulation and Menstrual Problems
As the ovary is not reliably producing an egg, female hormone levels produced by the ovary are often low. The uterus therefore receives very few messages to thicken its lining. As there is no orderly ovulation there is no drop in progesterone levels to trigger a period so bleeding does not occur. Patients with PCOS therefore often have absent or sparse periods.
Heavy periods or irregular frequent bleeding
This is more common in patients who are obese with PCOS. Sometimes the small and primitive follicles produce enough oestrogen to thicken the lining of the uterus but the compacting and balancing hormone, progesterone, is absent.
This can lead to the lining of the uterus becoming thicker and thicker and eventually undergoing a form of pre-cancerous change. This may be associated with quite heavy bleeding or irregular, frequent and even constant bleeding. Patients with this form of bleeding need investigation of the lining of the uterus by hysteroscopy and biopsy to make sure that they are not developing cancerous or pre-cancerous changes.
Obesity will be present in many patients with PCOS (50%). However many patients whose ovaries function in a PCOS way can be quite thin. Obesity can become self-perpetuating with PCOS in that the abnormal hormone levels being produced by the ovary can predispose to obesity. As explained above, once the fat tissue is laid down it then starts to produce female hormone which increases the level of disorganisation in the body’s environment which can lead to further obesity. Good weight control and dieting is an effective method of treating PCOS.
Acne and Abnormal Hair Growth (Hirsutism)
Increased levels of male hormone are produced by the ovary and to a lesser extent by any excess body fat. These increased levels of male hormone ravel to receptors in the skin and may trigger an outbreak of acne.
Different patients will have different sensitivities to these changes in male hormone so measuring the levels of these male hormones in blood tests is not predictive of how severe the skin changes will be. Patients also have different abilities to convert the male hormone which is present in blood into more active forms of male hormone which affect the skin and hair follicles of the skin.
Some patients will have their hair follicles activated by these increased male hormone levels and begin to develop excessive hair growth which is called hirsutism. This may occur particularly on the upper lip, chest, stomach and legs and arms. It may also be accompanied by a more coarse hair growth rather than the normal fine female hairs.
Infertility and PCOS
One of the most common presentations of patients with PCOS is difficulty becoming pregnant. Reading the information above it is easy to understand why. The most common problem associated with PCOS is disordered ovarian function and poor ovulation. This predisposes to infertility. However it must be stressed that there are many patients who have a mild form of PCOS who can become pregnant. Not all patients with PCOS fail to ovulate. Some may ovulate less regularly than a normal 28-day menstrual cycle but on each occasion that ovulation does occur an opportunity to become pregnant exists. Some patients may ovulate only a couple of times a year with PCOS but become pregnant during this time. Other patients who have very mild PCOS may even have a regular 28 day cycle and have only mild difficulty becoming pregnant. They will appear to be ovulating normally and the doctor will only discover that they have very mild PCOS when the ovary is stressed by challenging it with some ovulation inducing drugs.
There may also be an association between endometriosis and PCOS. The theories as to why endometriosis occurs are many but endometriosis would seem to be more common when there is a disordered hormonal environment and inadequate ovulation. There may be an indication to investigate patients with PCOS and infertility for associated endometriosis. Sometimes endometriosis may be increased when higher oestrogen levels occur in association with induced ovulation.
PCOS and diabetes
Recent research has shown that there is a link between PCOS and insulin resistance. Insulin is the hormone produced by the pancreas in the body. It is responsible for helping sugar to be metabolised into energy in the body. Patients who have PCOS are therefore more likely to have trouble handling a sugar load. When this occurs the condition is called diabetes. There is now a case for testing some patients with PCOS for early stages of diabetes. Patients with PCOS are 3-7 times more likely to develop diabetes later in life.
They are also more likely to develop diabetes during the course of a pregnancy. This is called gestational diabetes. Testing for diabetes should be done on PCOS patients at about 26 – 30 weeks of pregnancy. There is some research to suggest that drugs such as Metformin, which help control blood sugar levels can sometimes improve ovulation in patients with PCOS but these need to be used with caution. Also Metformin has been shown to NOT increase pregnancy rates.