What causes PCOS?

In PCOS there an imbalance between the pituitary gonadotropin luteinizing hormone (LH) and follicle-stimulating hormone (FSH), resulting in a lack of ovulation and an increased testosterone production, a male sex hormone.
Nobody knows exactly what causes this imbalance but it is felt that it is probably a combination of genetic and environmental factors.
Many women with PCOS have a weight problem and there appears to be a relationship between
PCOS and the body’s ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches and other food into energy for the body’s use or for storage. Many women with PCOS have insulin resistance, in which the body cannot use insulin efficiently. Since some women with PCOS make too much insulin, this leads to high circulating blood levels of insulin, called hyperinsulinemia. It is believed that hyperinsulinemia is related to increased androgen levels and it is possible that the ovaries react by making too many male hormones, androgens. This can lead to acne, excessive hair growth, weight gain (obesity), and ovulation problems as well as type 2 diabetes. In turn, obesity can increase insulin levels, causing PCOS to get worse.

Investigation of PCOS:

– Transvaginal Ultrasound (specific reporting on numbers of follicles is essential)
FSH/LH ratio (on day 3-5 of menses) or after progesterone challenge, avoid mid-cycle day 18-20 in women with cycles less than 35 days)
– Male hormone (Androgen) profile
– Blood sugar testing (Oral glucose tolerance ) if BMI >27
– Thyroid function tests
– Lipid profile (cholesterol, LDL and triglycerides) CONSULTANT

Treatment of PCOS

Lifestyle change and change in diet are absolutely paramount. Prophylactic use of Metformin in women with impaired glucose tolerance to prevent progression of diabetes is gaining increasing acceptance. The effectiveness of Metformin, in relation to ovulation induction, has been evaluated and has not been found to be useful on its own.
For women with irregular cycles who would like to conceive Clomiphene Citrate (CC) is the first choice therapy for women with PCOS (no previous treatments). In CC resistant women, a combination of CC plus Metformin could be tried before considering ovarian drilling or IVF as the final options. For women requesting cycle control, oral contraceptive pill with anti-androgen activity (Yasmin) should be offered.
SIS

In Summary

In PCOS presenting symptoms are highly variable
Not all women are infertile
Treatment of PCOS is highly individualised.
Lifestyle changes and exercise are mandatory as part of the management of the condition.
Metformin may have a role in treatment of PCOS and a six-month trial is worthwhile, especially in overweight PCOS.
Clomiphene is the initial treatment of choice in infertility.
Clomiphene plus Metformin may be more effective than ovarian drilling or IVF.

Conclusion

PCOS is a very common problem in women of reproductive age that has both short-term effects upon reproductive function and longer term effects upon the risk of diabetes and cardiovascular disease. The treatment of the condition is highly individualised and very much dependant on the presenting symptoms and needs of the woman in terms of fertility, cycle control, weight issues and hyperandrogenic symptoms.