Polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is a common hormonal condition that can affect girls and women in their reproductive years. It may cause disruptions to the menstrual cycle, skin and hair changes, as well as cysts on the ovaries.
PCOS is also known as polycystic ovarian syndrome or polycystic ovary disease.
What are the symptoms of polycystic ovary syndrome?
The symptoms of PCOS often begin in the late teens or early twenties. Each woman’s symptoms may be different – some women have a few mild symptoms, while others may have more severe changes.
Symptoms of PCOS may include:
- Irregular menstrual periods
- Heavy or prolonged periods
- Infrequent periods or no periods at all in adolescent girls
- Excessive hair growth (known as hirsutism): usually on the face, chest, back, buttocks or abdomen
- Overweight or obesity
- Thinning hair or hair loss from the head
- Acne or oily skin
- Fertility problems (difficulty getting pregnant)
- High blood pressure
Symptoms may also vary with different population groups. For example, women of Southeast Asian descent seem less likely to have excessive hair growth when they have PCOS.
What causes polycystic ovary syndrome?
The exact cause of PCOS is not known, but experts think it’s related to abnormal hormone levels. These hormonal changes may include:
- Resistance to insulin: Insulin is the hormone that controls the amount of glucose (sugar) in the blood. It works like a key, opening the door of the cells so that glucose can enter from the bloodstream. When someone has insulin resistance, their body doesn’t respond properly to insulin, so the body has to make more and more so that glucose can get into the cells.
- Over-production of male hormones: Insulin resistance can impact on your ovaries, causing them to produce excess amounts of male hormones (e.g. testosterone). Low-grade inflammation may also stimulate the ovaries to produce male hormones (androgens). This overproduction of male hormones can cause problems with the menstrual cycle and lead to changes such as excess hair growth on the face and body and acne.
Genetics is also thought to play a role. PCOS sometimes runs in families, and a woman who has relatives with PCOS (e.g. her mother, sister, aunt) is more likely to develop the condition.
Who gets polycystic ovary syndrome?
PCOS is a common condition. In Australia it is thought to affect 12–21 per cent of women of reproductive age. It is one of the leading causes of infertility, yet many women do not know they have it – up to 70 per cent of women with PCOS remain undiagnosed.
Some population groups have a higher risk of PCOS, including Aboriginal and Torres Strait Islander peoples. This may be related to having higher levels of insulin resistance and obesity.
How is polycystic ovary syndrome diagnosed?
There is no one particular test for PCOS. Your doctor will ask about symptoms and check your physical appearance for signs such as excess hair growth, hair loss and skin changes. They will also check blood pressure and may recommend additional tests.
Tests for PCOS
Your doctor may recommend the following tests to help make the diagnosis of PCOS.
- Blood tests to check hormone levels (such as testosterone).
- Blood tests to check cholesterol and glucose levels in the blood.
- Ultrasound scan to look at the ovaries and check for the presence of multiple, fluid-filled sacs (cysts).
Doctors generally diagnose PCOS if 2 or more of the following features are present.
- Irregular menstrual periods.
- Evidence of excess male hormone production. This may be seen in blood tests or shown by a woman’s physical appearance (physical features suggesting increased levels of male hormones include acne, excess hair on the face and body and male-pattern baldness).
- Polycystic appearance of the ovaries seen on ultrasound.
What are the complications of polycystic ovary syndrome?
PCOS can increase the likelihood of developing certain health problems later in life. That’s why it is important to have regular medical check-ups. Even though some PCOS symptoms may lessen after menopause, this can be the time when many of the long-term associated conditions appear, including:
- Type 2 diabetes. The difficulty in processing insulin that most women with PCOS have tends to get worse with age. Many women who have PCOS will be diagnosed with insulin resistance or type 2 diabetes. Because of this, it is important to start following a healthy diet and an exercise programme, especially if you are overweight, to improve sensitivity to insulin and reduce the risk of developing diabetes.
- High cholesterol levels. High levels of testosterone can cause levels of LDL-cholesterol (the so-called ‘bad’ cholesterol) to go up. This can lead to an increased risk of heart disease, stroke and heart attack. Women with PCOS may also have reduced levels of HDL-cholesterol (the ‘good’ form of cholesterol) and raised triglycerides (another form of fat in the blood).
- Metabolic syndrome. Metabolic syndrome is a cluster of signs and symptoms including abdominal obesity, high blood pressure, raised cholesterol levels and insulin resistance. People with metabolic syndrome have a greater risk of heart disease, heart attack and stroke.
- Endometrial cancer (cancer of the lining of the uterus). Women with PCOS have an increased risk of endometrial cancer.
Depression, anxiety and sleep problems are also associated with PCOS.
How is polycystic ovary syndrome treated?
Although PCOS cannot be cured, treatments are available to help with many of the symptoms. Treatment will depend on your symptoms and how severe they are, and whether you are planning a pregnancy or not.
Irregular menstrual periods
- Medicines for irregular menstrual periods or lack of menstrual periods are available. The combined oral contraceptive pill is the recommended approach in Australia. It can help to regulate menstrual periods as well as suppress the production of male hormones by the ovaries.
- Some women are unable to take the combined oral contraceptive pill. If this is the case, other medicines, such as a progestogen (a synthetic version of the female hormone progesterone) may be used. Oral progestogens (those taken by mouth) that may be prescribed include medroxyprogesterone acetate (brand names include Provera, Ralovera) or norethisterone (e.g. Micronor, Noriday, Primolut N) . An intrauterine device (IUD) called a levonorgestrel-releasing intrauterine system (brand name Mirena) may be recommended for some women.
- Medicines used to regulate menstrual periods can also help protect against endometrial cancer.
- In women who do not tolerate hormonal treatment, a diabetes medicine which helps your body make better use of the insulin it produces - metformin (brand names include Diabex, Diaformin, Glucomet, Glucophage) - may help to increase the frequency of menstrual periods. Metformin can also help women with PCOS lose weight as well as helping control excess body hair.
Type 2 diabetes, insulin resistance or impaired glucose tolerance
- Women who have insulin resistance can reduce their risk of progressing to impaired glucose tolerance or type 2 diabetes by losing weight through lifestyle changes (healthy eating and increased physical activity).
- In women who have impaired glucose tolerance or type 2 diabetes, treatment with metformin may be useful.
Overweight or obesity
- Women who are overweight or obese will benefit from lifestyle changes including a healthy eating plan and increased levels of physical activity, which can help with weight loss. Advice from a dietitian and exercise expert (e.g. physiotherapist or exercise physiologist) may be helpful.
- While not all women with PCOS have problems getting pregnant, some women may need assistance to get pregnant.
- Making lifestyle changes (e.g. adopting a healthy eating plan, increasing levels of physical activity, and quitting smoking if you smoke) may help improve fertility.
- If lifestyle changes don’t help, your doctor may refer you to a specialist in reproductive medicine. Medicines may be prescribed to improve fertility. Medicines include clomiphene (e.g. Clomid, Serophene, Fermil), which stimulates the ovary to grow follicles so that an egg is released mid-cycle. Sometimes metformin can help stimulate ovulation, and it may be used alone or in combination with clomiphene.
- Injections of synthetic hormones called gonadotrophins, similar to the ones you produce naturally, are another option.
Excessive hair production
Treatment of unwanted excess hair (hirsutism) may involve the following.
- Physical removal of the hair: e.g. through waxing, laser or electrolysis.
- Topical (applied to the skin) treatments, such as eflornithine (Vaniqa cream), can slow down the regrowth of facial hair in women.
- Oral (by mouth) medicines, such as the combined oral contraceptive pill. Some contraceptive pills contain an oestrogen and a small amount of an anti-androgen (a substance which blocks the effects of male hormones) called cyproterone acetate. This can be effective in keeping excess hair growth under control and improving acne. Anti-androgen therapy may also be used on its own. Examples include spironolactone (Aldactone, Spiractin) and cyproterone acetate (e.g. Androcur, Cyprone).
- You should be aware that these medicines may take some time to work. You may want to remove any existing hair growth, as medicines aren’t effective in getting rid of existing excess hair. Use a method such as bleaching, waxing or electrolysis.
What can I do if I have polycystic ovary syndrome?
If you have PCOS it is important to work in partnership with your doctor to manage the symptoms and reduce the risk of complications. Your doctor may suggest you follow a special diet to try to normalise your insulin levels and keep your cholesterol levels normal. Doing regular physical activity and losing weight are also important and can help some women with PCOS to become pregnant. Physical activity and healthy eating are also the key factors in reducing your risk of metabolic syndrome, diabetes and heart disease.
2. Boyle J, Teede HJ. Polycystic ovary syndrome: An update. Australian Family Physician 2012;41:752â€“56. http://www.racgp.org.au/afp/2012/october/polycystic-ovary-syndrome/ (accessed May 2016)
3. Mayo Clinic. Polycystic ovary syndrome (PCOS) (updated 3 Sep 2014). http://www.mayoclinic.org/diseases-conditions/pcos/basics/definition/con-20028841 (accessed May 2016).