Polycystic Ovary Syndrome (PCOS)
Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine (hormonal) disorders in women of reproductive age. PCOS can affect the woman’s menstrual periods, ability to get pregnant (fertility), hormones, heart, veins and even physical appearance.
The cause of PCOS, which can be seen in 5-10% of women, is not fully understood. Abnormal levels of LH hormone released from the pituitary and high androgen levels affect the normal functions of the ovaries. To explain what these hormonal disorders are causing, it is first necessary to know the normal menstrual cycle.
In the normal menstrual cycle (periods), the hypothalamus-pituitary, ovaries and uterus prepare the body for pregnancy by working in a certain sequence and order every month. FSH and LH, secreted from the pituitary gland ensures release of female hormones (progesterone and estrogen) from the ovaries. In the first half of the menstrual cycle, slight elevations in FSH stimulate the development of the ovarian-containing follicle. Then, this follicle begins secreting estrogen. Estrogen thickens of the intrauterine tissue (endometrium) and ensures release of high doses of LH from the pituitary gland. In the middle of the menstrual cycle, the LH peak is thus formed, and subsequently the matured egg is released from the ovary (ovulation). In this period, if the egg is fertilized with sperm, the formed structure progresses into the uterus through the fallopian tubes and pregnancy occurs. Both estrogen and progesterone are produced in the ovaries after ovulation. The purpose of this is to make the uterus suitable for the embryo to implant. If the egg released in ovulation is not fertilized with sperm, thickened intrauterine tissue prepared for pregnancy is shed after a certain period of time. This manifests itself as menstrual bleeding.
It is important to differentiate a normal follicle from the ovarian cyst. Many women may develop a cyst, but that doesn’t mean that they have PCOS.
After summarizing the normal menstrual cycle, let’s look at the situation in women with PCOS. In women with PCOS, many small cysts measuring 4-9 mm develop in the ovary. The problem here is that none of them have an ovulation capacity. Without ovulation, estrogen, progesterone, LH and FSH levels become unstable.
Studies show that there are more than one factor affecting the emergence of PCOS.
One of these factors is genetic predisposition. It is known that women with a family history of PCOS (in mother or sister) have a higher risk of developing PCOS. However, there is no evidence suggesting that PCOS is hereditary.
PCOS symptoms are triggered by imbalances in hormones that control the menstrual period. Testosterone is the main androgen (male sex hormone). This hormone is also produced by the ovaries in all women and turns into the main female sex hormone, estrogen. Overall, in women with PCOS, testosterone is produced more than usual. Excessive androgen levels cause acne, unwanted hair growth on face and body, weight gain and ovulation problems.
Insulin hormone is another hormone that plays a role in triggering PCOS symptoms. In fact, insulin resistance plays a significant role in development of PCOS. Insulin is a hormone produced by the pancreas that regulates the level of glucose in the blood. In many women with PCOS, a condition so-called “insulin resistance” is observed. In insulin resistance, body tissues resist the effect of insulin and as a result, the pancreas is forced to produce more insulin. Insulin hormone, which is very high in the body also affects the ovaries, causing hormonal imbalance. Excess insulin increases androgen production. The reason why women with PCOS tend to gain weight and have difficulty in losing weight is impaired insulin metabolism.
Irregular periods or absence of periods occur as a result of irregular ovulation or anovulation (absence of ovulation)
Infertility, recurrent miscarriages
Increase in unwanted hair growth in arms, legs, belly and back, color darkening and thickening of the hair on these areas, male pattern hair loss
Oily skin in the face, chest and back areas and acne
Weight problems; obesity, gaining weight quickly and having a hard time losing weight
Depression and mood changes
Sleep apnea, snoring
High blood pressure (hypertension)
In women with PCOS, all the hormones necessary for an egg to fully mature cannot be produced. Since none of the eggs can mature and release, ovulation cannot occur and the progesterone cannot be produced. In the absence of progesterone, periods may become irregular or absent.
Irregular menstrual periods (menstrual cycle) and the absence of ovulation increase the production of estrogen in woman, while they stop the production of progesterone. Progesterone is the hormone that causes periodic shedding of the lining of the uterus (endometrium) every month. In the absence of progesterone, the intrauterine thickens, resulting in heavy or irregular bleeding. Over time, this increases the risk of hyperplasia (tissue overgrowth) and cancer.
Cysts that can emerge in PCOS are not harmful. Surgical intervention is not required for these cysts and they do not cause ovarian cancer.
However, hormonal irregularities observed in PCOS elevate the risk of heart disease, diabetes and uterine cancer later in life. In more than 50% of women with PCOS, diabetes or impaired glucose tolerance can occur before age 40.
Women with PCOS have high LDL (“bad” cholesterol) levels, low HDL (“good” cholesterol) levels, a higher risk of high blood pressure (high blood pressure), and women with PCOS have a 4-7 times higher risk of heart attacks compared with other women of the same age.
Diagnosis of Polycystic Ovary Syndrome (PCOS)
There is no specific, single test to make the diagnosis of PCOS. PCOS can be diagnosed based on the person’s symptoms, blood test results, and physical examination. In order to diagnose PCOS, at least two of the following findings should be observed:
The image of polycystic ovary (PCO) on ultrasound; presence of multiple ovarian cysts with the size that does not exceed 8-10 mm.
Absence of ovulation (anovulation); the menstrual period of a woman with PCOS may be irregular or absent.
Chronic hyperandogenism; overproduction of androgens.
It is not sufficient for the diagnosis of PCOS to have only PCO image on ultrasound, absence of ovulation or presence of hyperandogenism. At least two of these findings should be found simultaneously.
There is no standard treatment for PCOS. The treatment method differs according to the complaints observed. Some of the treatment methods are as follows:
1.Lifestyle change: Losing weight, nutrition and exercise
The first step in the treatment of PCOS is to maintain the ideal weight with a healthy diet and exercise. Many women with PCOS are overweight or obese. Making healthy changes in eating habits; avoiding processed and sugar-added foods, consuming cereal products, fruits, vegetables, and lean meats helps keep blood sugar low, regulate insulin use, and hormone levels. Getting rid of excess weight often contributes to increase fertility (reproductive potential) without the need for medical treatment by regulating the menstrual cycle.
Daily exercise regulates the use of insulin in the body and helps to improve many complaints/symptoms of PCOS.
Many of the symptoms and health risks observed in women with PCOS can be eliminated with healthy nutrition, exercise and healthy lifestyle without using medical treatment methods.
2.Using drugs that increase insulin sensitivity
Recent studies show that drugs used in the treatment of type 2 diabetes can also be effective in the treatment of PCOS.
Metformin is the most promising of the drug used for this purpose. Metformin affects control of insulin on blood sugar level and decreases testosterone production. In addition, it has been observed that it slows abnormal hair growth and regulates ovulation after a few months of use. Recent studies also show that metformin has other positive effects, such as a decrease in body mass and an improvement in cholesterol levels.
3.Regulation of menstrual periods
Birth control pills allow regular periods to occur in women with PCOS and improve complaints such as acne, hirsutism (excessive hair growth on the face and body).
4.Dealing with skin and hair problems
In women with acne and excessive hair growth problems, the use of birth control pills (oral contraceptives) along with low-dose anti-androgen drugs may be recommended. In resistant cases, higher doses of anti-androgen drugs can be used. Anti androgens can improve excessive hair growth (hirsutism) and male pattern baldness. However, these drugs have no effect on fertility.
With medications, symptoms usually decrease within a few months. These drugs cannot provide definitive treatment. Therefore, symptoms/complaints may appear again when you stop taking the medications.
Improving fertility (reproductive potential)
Other possible causes of infertility should be investigated in women and men before using assisted reproductive techniques. The problem with PCOS seen in women is usually the absence of ovulation. This problem can be solved with the treatment methods that enable ovulation.
“Clomiphene citrate” is the most commonly used drug for ovulation treatment; it can ensure ovulation in 80% of the cases and pregnancy in 60-70% of them. In women where clomiphene citrate use does not benefit, medications called “gonadotropins” are used. Between 50-70% of pregnancy rates that can be achieved with these drugs and several treatment cycles may be required to see the effect.
Another way to ensure ovulation is the surgical method called “laparoscopic ovarian drilling”. In this method, which is used in women with PCOS where drug therapy does not work, male hormones can be reduced and ovulation can be achieved. Pregnancy rates are around 50-70% with this surgical method called “laparoscopic ovarian drilling”. İt is a low cost treatment method.
If pregnancy does not occur with all these medication and surgical treatment methods, IVF (In vitro fertilization) can be used. IVF is more costly than other methods, but has the best rates for conception.
Generally speaking, insulin resistance underlies PCOS. Just overcoming insulin resistance will correct PCOS in the vast majority of patients. For this, it is crucial to reach the ideal weight and to avoid flour and sugar.