POLYCYSTIC OVARY SYNDROME (PCOS)
Polycystic ovary syndrome (PCOS) is the most common reproductive disorder in women of child bearing age. PCOS is a result of ovarian dysfunction that manifests with irregular periods or no periods (irregular ovulation or no ovulation) and varying degrees of increased androgen effects (i.e. high testosterone or increased hair growth and/or acne) as well as polycystic appearing ovaries (multiple small follicles in the ovaries).
PCOS is diagnosed by the inclusion of any two of the parameters above, along with exclusion of other diseases that would present with similar findings. There is no single test or symptom that would indicate that a person has the disease, but rather the diagnosis of PCOS is made by a combination of symptoms and blood testing.
PCOS can be associated with other diseases, such as thyroid disease and elevated prolactin hormone levels (the hormone that makes the breast milk). Women should be tested for the presence of these disorders if they have PCOS type symptoms. Additionally, PCOS patients are at an increased risk for pre-diabetic conditions that can be diagnosed by an elevated insulin level and/or elevated glucose level (glucose intolerance) or even may have frank diabetes at the time of the diagnosis of PCOS. Therefore, it is very important to screen patients for diabetes at the time of diagnosis of PCOS. Patients who are overweight or obese are at a higher risk for having or developing diabetes in the future.
In some of the PCOS patients who do not ovulate at all or ovulate very rarely, a condition called endometrial hyperplasia (pre-cancerous cells in the uterus) or endometrial cancer can be present. If necessary, an endometrial biopsy (small amount tissue taken from the inside of the uterus) can be done to identify such abnormal cells. If diagnosed, treatment is necessary with hormones to revert these abnormal cells back to normal functioning endometrial cells.
Common problems with PCOS are irregular periods and sometimes heavy bleeding, unpredictable periods, increased hair growth and acne formation, weight gain and infertility. Treatment is based on the complaint and the patient’s plans on becoming pregnant.
If the initial work up is diagnostic of PCOS and other diseases are all eliminated by testing, the treatment options are discussed. If pregnancy is not desired, patients can use birth control pills to regulate periods, which also provide adequate contraception.
If pregnancy is desired, ovulation induction (medication to grow and mature eggs) commences. The first line in treatment is clomiphene citrate (Clomid) tablets. This medication is taken for 5 days starting on the third or the fifth day with an initial dose or 50 mg/day. If ovulation is established with this dose, the same dose is continued for 3-6 months until pregnancy is established. If ovulation is not established with this dose, then the dose is increased at increments of 50 mg every month. Injection of sperm into the uterus (Intrauterine insemination – IUI) at the time of ovulation can also be utilized with Clomid and may be beneficial in mild male factor cases.
Additional ovulation induction medications that can be taken orally are Metformin and Letrozole. Whereas these medications are quite popular currently, their effectiveness and safety is not as established as Clomid. A recent study concluded that Clomid was better than Metformin in establishing ovulation, pregnancy rates and most importantly live births. Combination of the two medications is no better than Clomid alone for infertility.
Metformin has also been used to reverse the problems with the glucose (sugar) metabolism in the body, especially in obese PCOS patients. It appears to decrease the risk of developing diabetes on the long run in the older population, but it is not as effective as diet and exercise. In the younger population, it is still not determined which patients will benefit the most and how long they need to be on the medication. Therefore, metformin should not be used routinely in all patients with PCOS regardless of their desire for fertility.
As a general rule, if a patient does not ovulate on Clomid or does not become pregnant, the next line of treatment is injectible FSH medication. This type of treatment allows patients to ovulate 100% of the time. IUI treatment may also be combined with the injectible FSH medications and is usually recommended to maximize chances of pregnancy. This type of treatment can also be continued for 3-6 cycles, unless there are other factors involved.
Another treatment option for patients with PCOS is in vitro fertilization (IVF). This type of treatment provides the highest pregnancy rate compared to all other forms of treatment, but carries the risk of overstimulation (ovarian hyperstimulation) especially in PCOS patients. The risk of OHSS can be reduced significantly by one of the protocols designed by Dr. Bayrak for each individual case. This type of treatment involves using injectible FSH medication along with other medications, egg aspiration and fertilization in the laboratory. Embryos are transferred into the uterine cavity in 3-5 days following egg aspiration and fertilization.
Surgical treatment of PCOS involves destruction of some of the ovarian tissue (laparoscopic ovarian stromal cauterization) to allow ovulation and regular menstrual cycles. This type of treatment is no longer preferred because of the high success rate with the medical approach. In some cases, surgical approach can be useful, but this type of treatment should be individualized. Surgical treatment does not improve metabolic parameters (such as elevated insulin or glucose levels) and also does not decrease the risk of diabetes.
Weight loss and exercise should be routinely recommended to patients with PCOS because most patients tend to be overweight or obese. Weight loss of 10-15% of the body weight is sufficient enough to allow ovulation in most cases. Additionally, the risk of developing diabetes, high cholesterol and heart disease also significantly decreases with weight loss and establishment of normal weight.
You can download Dr. Bayrak’s Publications from the links below:
Metformin and PCOS PDF
PCOS – Insulin resistance