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Polycystic Ovary Syndrome (PCOS)

What is Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the commonest endocrine condition affecting 15-20% of woman of the reproductive age. The presence on an ultrasound scan of multiple, small, fluid filled cysts in the ovaries is known as polycystic ovaries, which may exist per se independent of the complex syndrome. To make an accurate diagnosis of PCOS, according to published recommendations there must be two out of three of the following criteria:

• Multiple small cysts on one or more ovary. One or more enlarged ovary may also be diagnostic
• Clinical symptoms or blood test evidence of raised levels of androgens (male hormones) such as testosterone
• Irregular periods or evidence that ovulation is not occurring

In PCOS, the cysts may be accompanied by an imbalance of sex hormones, specifically elevated androgens. Normally women have both oestrogens (female hormones) and androgens (male hormones). In PCOS the balance is tilted towards overproduction of androgens. PCOS is associated with irregular, infrequent or even absent periods. If the periods are irregular, it is unlikely that ovulation is occurring. As a result, women may experience problems conceiving (subfertility). Further, women with PCOS may also suffer repeated early pregnancy losses (also known as recurrent miscarriage).

Women with PCOS may have difficulty controlling their weight. Being overweight makes the symptoms even worse. Conversely weight loss can lead to a dramatic improvement in the full spectrum of symptoms.

Treatment of PCOS
An association between PCOS symptoms and a significant reduction in health-related quality of life (physical, psychological and social aspects) has been demonstrated. Therefore, treatment has to be tailored according to the main symptoms at presentation on an individual basis.

Weight loss and Diet
If overweight or obese then weight loss must be the starting point as it helps to reduce the insulin levels and improve the overall hormone imbalance. Ideally the body mass index (BMI) should be 20-25 (BMI = W/H2, W is weight in Kg and H is height in metres). Symptoms will improve significantly and may even disappear with weight loss. In some cases this may be the only treatment needed to restore ovulation and regular periods.

The most appropriate diet for women with PCOS is one that promotes more stable levels of blood sugar and lower levels of insulin. Carbohydrates should be spaced throughout the day to avoid peaks in blood sugar and insulin production. Importantly, carbohydrates should be combined with proteins and/or fat rather than be eaten alone. It is also best to avoid carbohydrates that trigger more hunger or cravings.

Drugs may be used to aid weight loss. These act by either reducing gastro-intestinal absorption of fats (Orlistat) or by suppressing appetite in the brain (Sibutramine). In severe cases of obesity, the gastric bypass and other similar approaches should be considered.

Hormone preparations for irregular periods
The combined oral contraceptive pill (COC) is given to regulate the menstrual cycle and to reduce the risk of endometrial cancer (cancer of the lining of the womb). The COC pill causes elevated circulating levels of sex hormone binding globulin (SHBG) in the blood which works ‘mopping’ up the androgens, resulting in improvements in the symptoms of acne and unwanted excessive hair.

Dianette is a hormone preparation containing the anti-androgen cyproterone acetate (CPA). Dianette is not licensed as a contraceptive but solely for treatment of acne and/or hirsutism. There is a small risk of deep venous thrombosis (DVT) and it is advisable to consider changing treatment 6 months after symptoms have improved. An individual risk assessment needs to be made taking into account all the important factors. Some women may choose to take Dianette long term if other options are not suitable. CPA may take 6-12 months to improve symptoms. In some severe cases, additional CPA can be added on day 5-15 of the menstrual cycle.