Can PCOS be prevented?
If there is a genetic influence, then some people are more likely to get PCOS than others. However, it seems likely that you cannot alter your predisposition to PCOS. There is no current proof of any benefit of preventative weight loss, but the best advice for overall health is to maintain a normal weight or BMI, especially if you have strong indicators that PCOS could affect you. These indicators are:
- a tendency in the family towards non-insulin dependent (Type 2) diabetes.
- a tendency towards early baldness in the men in the family (before 30 years of age).
- the knowledge that a close relative already has PCOS.
. What are the symptoms?
The ways in which PCOS shows itself include:
- absent or infrequent periods : a common symptom of PCOS. Periods can be as frequent as every five to six weeks, but might only occur once or twice a year, if at all.
- increased facial and body hair (hirsutism): usually found under the chin, on the upper lip, forearms, lower legs and on the abdomen (usually a vertical line of hair up to the umbilicus).
- acne: usually found only on the face.
- infertility: infrequent or absent periods are linked with very occasional ovulation, which significantly reduces the likelihood of conceiving.
- overweight/obesity: a common finding in women with PCOS because their body cells are resistant to the sugar-control hormone insulin. This insulin resistance prevents cells using sugar in the blood normally and the sugar is stored as fat instead.
- miscarriage (sometimes recurrent): one of the hormonal abnormalities in PCOS, a raised level of luteinising hormone (LH - a hormone produced by the brain that affects ovary function), seems to be linked with miscarriage. Women with raised LH have a higher miscarriage rate (65 per cent of pregnancies end in miscarriage) compared with those who have normal LH values (around 12 per cent miscarriage rate).
These symptoms are related to several internal changes.
- Hormonal abnormalities, including:
- raised luteinising hormone (LH) in the early part of the menstrual cycle.
- raised androgens (male hormones usually found in women in tiny amounts).
- lower amounts of the blood protein that carries all sex hormones (sex-hormone-binding globulin).
- a small increase in the amount of insulin and cellular resistance to its actions.
Most women with PCOS will have the ultrasound findings, whereas the menstrual cycle abnormalities are found in around 66 per cent of women and obesity is found in 40 per cent. The increase in hair and acne are found in up to 70 per cent whereas the hormone abnormalities are found in up to 50 per cent of women.
It is likely that there are different stages of the disease throughout life. Younger women tend to have substantial difficulties with their periods, whereas older women have other problems such as diabetes and hypertension (high blood pressure), though their period patterns tend to become more regular.
Women with PCOS also have an increased risk of strokes and heart attacks, but their death rate from these conditions is not increased (Wild et al, 2000).
Women with PCOS may also have an increased risk of endometrial cancer (cancer of the lining of the womb), particularly if they have infrequent or absent periods.
How is PCOS diagnosed?
The diagnosis is based on the patient's symptoms and physical appearance. If the diagnosis seems likely because the patient's history contains many of the symptoms described already, certain investigations are done to provide confirmatory evidence or to indicate another cause for the symptoms.
These include:
- blood tests such as:
- female sex hormones (at a certain point in the cycle if possible)
- male sex hormones
- sex-hormone-binding globulin
- glucose
- thyroid function tests
- other hormones, eg prolactin.
Your own GP can do the initial blood investigations, ensuring they are carried out at the correct time of the cycle if appropriate. Your GP may be able to arrange an ultrasound scan.
Once the diagnosis is made, nothing more needs to be done for some women, eg if their fertility is not an issue, if their weight is within normal limits, and if they do not have excess body hair.
If any of the symptoms are an issue, then further advice and treatment, and possibly specialist referral is needed.
What else could it be?
The other conditions likely to cause abnormal periods include raised levels of prolactin and of thyroid stimulating hormone (TSH). Both these hormones are produced from a particular part of the brain, the anterior pituitary.
Raised prolactin levels can occur together with headaches and some disturbances of vision whereas raised TSH levels indicate low thyroid hormones (hypothyroidism). Both these conditions lead to suppressed ovulation and infertility.
Increased hair and acne reflect an increase in male hormones (androgens) in the blood. Other conditions can cause such an increase.
Rarely, adrenal disorders or tumours cause increased androgens. In these conditions, hirsutism usually develops quite rapidly; previously normal periods may also stop and, occasionally, muscle weakness occurs.
Loss of, or changes in, female aspects of body shape and appearance (secondary sexual characteristics), especially reduction in breast size, may also occur. As the androgen excess progresses, the voice can deepen and the clitoris can increase in size (clitoromegaly). If these serious medical disorders are present, the male hormone levels will be considerably increased, way above those found in PCOS, and specialist treatment should be arranged.
What can you do for PCOS?
There are several things that an individual can do if they have a tendency towards developing some or all of the elements of PCOS. Much of this involves lifestyle changes to ensure that your weight is kept within normal limits (BMI between 19 and 25).
In addition, because there is a likelihood of developing diabetes in later life and a slightly higher risk of heart disease, low-fat and low-sugar options should be considered when making choices about what to eat or to drink.
Weight loss, or maintaining weight below a certain level, will have the short-term benefit of increasing the likelihood of successful treatment and the long-term benefits of reducing the risk of diabetes and heart disease (Galtier-Dereure et al, 1997).
What can your doctor do?
Your family doctor will be able to provide many of the drug treatments available (although these are probably best taken in consultation with a specialist). Treatments aim to improve several aspects of PCOS, including:
- fertility, via the stimulation of ovulation
- reduction of the insulin resistance
- reduction of the increased hair.
Treatments
The range of treatments available and their application are listed in Tables 1 and 2.
Table 1 deals with the treatments for improving fertility in women with PCOS (Homberg, 1998; Pirwany et al, 1999; Farquhar et al, 2000; Hughes et al, 2000a; Hughes et al, 2000b; Hughes et al, 2000c).
Table 2 deals with the treatments for other features of PCOS including hirsutism, irregular or absent periods and obesity. The evidence in favour of using of these medications to improve symptoms is not strong (Lee et al, 2000).
| Table 1: Treatments to improve fertility in women with polycystic ovary syndrome | |||
| Drug and mode of action | Benefits | Risks | Effects on life quality |
| Clomifene: mild stimulant of ovarian function (Hughes et al, 2000a). | Effective method to achieve ovulation. | 1. Very low risk of ovarian hyperstimulation syndrome. | 1. Simple easy method of treatment with tablets to be taken by mouth, for five days each month. |
| 2. Possible risk of multiple pregnancy if several mature follicles develop. | 2. Minimal effects while taking tablets, though some develop headaches. | ||
| 3. Increased risk of ovarian tumours in women having more than 12 cycles of treatment. | 3. Obvious benefit if pregnancy ensues (pregnancy also lowers the increased risk of ovarian tumour back to that of the normal population). | ||
| Gonadotrophin injections: direct stimulation of the ovarian follicles to grow. | Ovulation rates of over 90 per cent in most women and pregnancy rates of 20-25 per cent per cycle. | 1. Ovarian hyperstimulation syndrome. | 1. Require daily injections of hMG or FSH derived from urine or recombinant FSH (Hughes et al, 2000c). |
| 2. Multiple pregnancy if many mature follicles develop. | 2. Several studies suggest the benefits of taking a second drug in conjunction. This should suppress LH and improves the chances of an ongoing pregnancy. | ||
| Metformin: many actions - eg reduction of male steroid production by the ovaries. | Improves the uptake of sugars into cells by insulin. Ovulation rates up to 90 per cent of cycles (Pirwany et al, 1999, Galtier-Dereure et al, 1997). | No significant associated risk. | Considerable gastrointestinal upset reported - particularly diarrhoea - which is somewhat improved by reducing the daily dose. |
| Gonadotrophin releasing hormone agonists: stimulate the release of natural sex hormones from the brain. | Lowers LH concentrations and reduces the likelihood of miscarriage (Homberg, 1998, Hughes et al, 2000b). | Needs to be used in conjunction with FSH injections and therefore all the above risks also are present. GnRH agonists themselves have little risk in short-term use. | |
| Table 2: Treatments for other features of polycystic ovary syndrome | ||
| PCOS feature | Available treatment | Comments |
| Raised androgen (male sex hormone) level | Metformin | 1. Metformin reduces the abnormal findings of raised androgens and decreased sex-hormone binding protein in the blood, but it can cause considerable gastrointestinal upset - particularly diarrhoea - which is somewhat improved by reducing the daily dose. It is less effective in women of normal weight and does not improve hirsutism. |
| Irregular periods | Metformin | 1. Return of periods in 90-95 per cent of women. |
| Obesity | Metformin | 1. Several studies have examined the effect on weight loss; the majority support its effectiveness. |
| Hirsutism | Combined oral contraceptives, especially containing the anti-androgen cyproterone acetate (eg Dianette). | 1. These increase the levels of the sex hormone carrier in the blood, leaving less androgen free to cause hirsutism. |
| 2. It may take six months before any noticeable improvement occurs and two to three years to achieve the maximum benefit from anti-androgens because of the length of the growth-cycle of hair. | ||
| Hirsutism | Finasteride | 1. Finasteride reduces the amount of hair by preventing androgen getting into cells. It can cause headache and depression, and contraception is essential to avoid accidental exposure to a foetus. It is useful as a second-line drug for the treatment of excess hair but is not licensed for this purpose, and some pharmacies have made inappropriate comments to my patients when filling prescriptions, affecting their likelihood of taking the treatment. |
| Endometrial cancer (cancer of the womb lining) | Progestogens, medroxyprogesterone acetate. | 1. Stops endometrium (womb lining) from developing, and counteracts any tendency towards cell abnormalities and cancer. Occasional bloating and fluid retention occur. |
It does seem sensible to advise women with absent or very infrequent periods to take occasional progestogen therapy to 'oppose' the oestrogen and minimise the risk of endometrial cancer.
Non-drug treatments
Ovarian diathermy (surgery that uses heat to alter ovarian function) is thought to reduce the amount of androgen secreting tissue in the ovaries, leading to resumption of ovulation in up to 80 per cent of women. The risks include those of having a laparoscopy and a theoretical risk of ovarian damage from the diathermy. The benefits include resumption of ovulation in a simple manner, with effects lasting six to nine months (Farquhar et al, 2000; Homberg, 1998).
There is a range of non-drug treatments available for hirsutism. Once a serious increase in male hormone levels has been excluded, then local cosmetic options can safely be considered. These include:
- bleaching
- depilatory preparations
- waxing
- plucking
- laser hair removal
- electrolysis
- shaving.
Each is usually effective but expert advice should be taken, because each method has its own problems.
Bleaching and depilatory preparations can occasionally cause a local allergic reaction.
Waxing and plucking often break the hair shaft rather than actually remove it from the hair follicle and, therefore, should be considered to be little more effective than shaving.
Electrolysis and laser hair removal usually give the most prolonged action but both are expensive and cannot tackle large areas of the skin. Electrolysis is painful and laser removal may not be permanent.
Damage to skin or follicles can also occur with either. Waxing, plucking and shaving can lead to inflammation and infection of hair follicles, requiring topical antibiotic creams.
Sugaring is less likely to provoke this result than waxing. Best results will be obtained from shaving if hypoallergenic shaving soaps and razors are used. There is no evidence that plucking, waxing or shaving will encourage increased hair growth.
What is the outlook?
Living with PCOS means different things for different women. This is because women experience the condition in different ways and have more or less severe symptoms depending on their situation. In addition, as women get older, some symptoms change with age; hirsutism become less as hair distribution patterns change with advancing age and as the male hormones in the blood revert to more normal levels (Winters et al, 2000).
Women with PCOS are more prone to some serious conditions. These include an increase in the likelihood of developing diabetes (usually Type 2 diabetes (non-insulin dependent diabetes) and of developing cancer of the womb lining (endometrial cancer).
They also are more at risk of hypertension (high blood pressure) and high cholesterol, though if weight is controlled, high blood pressure is less likely to occur (Wild et al, 2000). Therefore, it makes sense to watch for symptoms suggestive of these conditions and to see your doctor should any suspicious symptoms be present.
For endometrial cancer, these include irregular spotting or bleeding in the 40 to 50 year age group or any bleeding after themenopause. For diabetes, these include unusual thirst requiring large amounts of fluids, tiredness, and passage of increased amounts of urine, particularly at night.
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