Diagnosing & Treating Infertility caused by PCOS – Polycystic Ovarian Syndrome
What is PCOS and the Symptoms of Polycystic Ovarian Syndrome?
Polycystic ovarian syndrome (PCOS) is a term given to a condition that affects a subset (approximately 10-20%) of women with ovulatory dysfunction. The condition was initially described in 1935 by Dr. Stein and Dr. Leventhal as an anatomical disorder based on appearance of ovaries at hysterectomy. It was not until the 1960s that PCOS was recognized as an endocrine disorder and it was finally recognized to actually be a metabolic disorder in 2000.
The diagnostic criteria established by the National Institute of Health in 1990 require the presence of both a chronic failure to ovulate as well as clinical evidence of excess male hormone (androgen) production. Symptoms associated with androgen excess include acne, deepening of the voice, and excessive hair growth in a male pattern. In 2003, the diagnostic criteria for PCOS were revised to include rare or a complete absence of ovulation combined with either evidence of male hormone production or a polycystic ovarian appearance diagnosed by ultrasound.
Polycystic Ovarian Syndrome Increases the Risk of Endometrial Cancer, Type II Diabetes, and Heart Disease
Women who are diagnosed with polycystic ovarian syndrome are at an increased risk of developing endometrial cancer as well as components of the Metabolic Syndrome including Type II diabetes, elevated cholesterol and triglycerides, hypertension, and heart disease. In the United States, there is a much higher incidence of impaired glucose tolerance and progression to type II diabetes in women who have polycystic ovarian syndrome; therefore, all women with this diagnosis, particularly those who are overweight, should be screened for abnormal glucose metabolism.
PCOS is the most common endocrine disorder in women of reproductive age affecting up to 8% of all women. The incidence is higher in certain ethnic populations affecting approximately 5% of Caucasian women and up to 15% of Hispanic or Latino women. Most women who have polycystic ovarian syndrome give a history of irregular cycles often from the time of their first menses. They often also exhibit excess androgen activity as well as an increased waist to hip ratio. The laboratory evaluation of PCOS should also include tests designed to exclude other conditions that can cause irregular ovulation such as thyroid abnormalities and excessive production of prolactin.
Obesity and the Treatment of Polycystic Ovarian Syndrome
If women are obese, a fasting lipid profile as well as a glucose tolerance test should be performed. For women who are diagnosed with polycystic ovarian syndrome and are overweight, the first line therapy for management of the condition is weight loss. The best diet and exercise regimens have not been standardized, although a low calorie diet with reduction of carbohydrate intake and increased physical activity are recommended. For women who are morbidly obese, there is a strong recommendation to consider the use of bariatric surgery. The ideal amount of weight loss is unknown, but clinically significant improvements in the condition has been reported with as little as a 5% decrease in overall body weight.
In most cases, treatment of the obese PCOS patient should precede ovulation induction. Concurrent medications used to treat polycystic ovarian syndrome include insulin-sensitizing agents such as metformin. The use of metformin should be restricted to patients with demonstrated glucose intolerance. Decisions about continuing metformin during pregnancy should be left to obstetricians who are providing prenatal care. These decisions should be based on the careful evaluation of the risks and benefits – both to the patient as well as to her fetus. Almost all patients with PCOS will require treatment with some type of ovulation induction medication (clomiphene citrate or gonadotropin therapy) in addition to metformin in order to achieve ovulation and pregnancy.