Polycystic Ovarian Syndrome

iStock 000004101720SmallPolycystic ovarian syndrome is a bit of a misnomer, because only about 3/4 of women with this condition actually have classic polycystic ovaries on ultrasound. This condition would better be called "lack of ovulation because of insulin resistance". Insulin resistance is a decreased responsiveness of cells all over your body, to the hormone "insulin". Some people are born with a genetic tendency toward it (check if anyone in your family has adult onset diabetes, even in old age, or gestational diabetes when they were pregnant - insulin resistance runs in families). Nearly everyone become insulin resistant with weight gain and as a society we are gaining weight rapidly.

The ovaries need your body to be exquisitely insulin sensitive to ovulate each month. As your body becomes insulin resistant, you stop ovulating regularly, and your ovaries go into a "steady state" instead of a "cycling" state. When they are in a steady state, they produce high levels of the hormone "estrogen" and very little of its balancing hormone "progesterone". Estrogen acts like fertilizer on the endometrial lining making it thick and plush, while progesterone ("Pro" - gestation) trims the lining down and functions as a "lawn mower" on the lining of the uterus. So as your ovaries go into a steady state, your periods spread out and happen less and less often.

In the meantime, the ovaries continue to try to make eggs. They produce the usual wave of small follicles (simple cysts), each containing an egg. Under normal circumstances, a wave of follicles is produced in the first few days of each month, and one of them gets bigger than all the rest, destroys the others, and releases its egg into the tube each month at midcycle. Following ovulation, the ovary produces large amounts of progesterone to counteract the effects of the estrogen exposure in the first half of the cycle.

But in the steady state, none of the wave of small follicles ever get to be the big dominant follicle that releases the egg and destroys the other follicles. Instead hundreds of them stay at the surface as small follicles, which often gives the impression on ultrasound of large "polycystic" ovaries. In fact they are normal ovaries, responding as any ovaries would, in an adverse metabolic environment. Normally, the large ovulatory follicle sets up a hormonal microenvironment within the ovary that makes the other smaller follicles disappear. If this doesn't happen, and the small follicles remain in a steady state, they produce androgens, such as testosterone. Testosterone causes skin changes such as acne, big skin pores, unwanted dark facial hair and body hair growth and male pattern balding. The insulin resistance can cause a brownish discoloration of the skin under the arms and in the groin area and cause skin tags.

Polycystic ovarian syndrome is a symptom of serious underlying metabolic problems, that in the long term increase your risk of heart disease, stroke, diabetes, sleep apnea, reflux, and a variety of estrogen related cancers, to name just a few. It always needs addressing, even if you decide not to pursue fertility treatment.

Work-up for polycystic ovarian syndrome involves looking carefully at your waist circumference (>35 inches is a cardiac risk factor), looking at your hormone levels, ruling out overt diabetes, looking at your cholesterol profile and at your cardiac risk factor markers. Often an ultrasound can be helpful in making sure that the overproduction of estrogen and underproduction of progesterone is not causing your uterine lining to grow abnormally, since PCOS can lead to cancers and precancers of the endometrial lining.


Treat the Insulin Resistance

First and foremost, correct the underlying metabolic problem - insulin resistance must be addressed with structured lifestyle management, including dietary change (low glycemic index), stress management, and more exercise, to induce body composition change while preserving or even strengthening lean body mass (muscle). A combination of lifestyle management and medical foods works well to correct most people's cholesterol problems, but occasionally statins are needed as a second line therapy. if necessary, medications to improve insulin resistance, such as Metformin, are sometimes also used in addition to structured lifestyle management. PCOS is a symptom of serious underlying metabolic problems that lead to heart disease, stroke, diabetes and estrogen related cancers if untreated.

Treat the Skin Problems

We look carefully at skin problems, such as acne and hirsutism (unwanted dark facial and body hair) associated with this condition and treat those specific conditions. Bear in mind that many acne treatments are best delayed if you are attempting pregnancy.

Hirsutism is unwanted facial and body hair. It is coarse and dark, often on the upper lip or the chin, or sides of the face. The high testosterone levels associated with PCOS are converted to a more powerful hormone, "dihydrotesterone," at the level of the skin. Dihydrotesterone permanently converts hair follicles to produce dark coarse hair ("terminal hair") in these areas instead of light "vellus" hair. The only way to stop the hair growth after this conversion happens is with laser hair removal or with electrolysis. However, conversion of more follicles from "vellus" to "terminal" hair producing will continue to occur if testosterone levels remain high. This can be stopped by becoming more insulin sensitive (weight loss, exercise, insulin sensitizers), and by medications such as Spironolactone and Vaniqa that prevent testosterone from being converted to dihydrotestosterone in the skin.

Treat the Irregular Menstrual Bleeding

Estrogen is a hormone of growth and acts like a fertilizer on the lining of the uterus that is supposed to shed and bleed every month. Progesterone acts like the "lawnmower", the "menstrual timekeeper". If you are not ovulating every month, either because of PCOS, or because of being in perimenopause, you are not producing adequate progesterone. The result is "fertilizer, fertilizer, fertilizer" and no "lawn mower" effect. It can lead to polyps, precancers and cancers over time. It can also lead to irregular, unpredictable and often heavy bleeding.

Diagnosing the problem and ruling out serious problems usually involves pelvic ultrasound and hysteroscopy, a brief office procedure in which we look inside the uterus with a camera and obtain a small sample of tissue (hysteroscopy), comfortably, with IV conscious sedation.

If serious uterine disease is not present, then treatment is often first aimed at improving insulin resistance and hormone balancing. This is almost always how we manage this problem when further fertility is desired. We try to use natural hormones wherever possible.

However, if the problem is severe and making it hard to exercise and eat properly and leave the house, because you are always bleeding and sometimes even becoming anemic, then more definitive action needs to be taken. If you are not trying to become pregnant, but still want more children someday, then the oral contraceptive pill may be a better way to go. If you are not trying to become pregnant, and are all finished having children, endometrial ablation is a great option, with minimal downtime. Outpatient minimally invasive laparoscopic hysterectomy is another option with some downtime, but far less than traditional hysterectomy. No matter what you decide, the underlying metabolic problem that caused the problem in the first place still needs serious long term attention, and we can provide it for you.

Debra Ravasia, updated 2017