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Polycystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a disorder characterized by hyperandrogenism (masculinizing signs such as hirsutism or acne, or high blood levels of male or male-like hormones), dysfunction of ovulation (abnormal release of an egg from the ovary that results in menstrual irregularities such as oligomenorrhea (infrequent periods) or amenorrhea (no periods)), and polycystic ovaries (as seen on a transvaginal pelvic sonogram).  Its cause remains unknown, and treatment is mostly symptom- and experience-based.  It is the most common hormonal abnormality affecting women of reproductive age, estimated to affect approximately 7% of women in the United States.

Women with PCOS experience a wide range of symptoms and health concerns, including abnormal menstrual cycles, infertility, obesity, metabolic problems (like diabetes and hypothyroidism), and hyperandrogenism.  This makes PCOS a complex condition to diagnose and treat because of how varied its presentation can be.

While there is some controversy surrounding the criteria for PCOS, most reproductive societies accept the Rotterdam Criteria (2003) for diagnosis.  The diagnosis of PCOS is based on two of the three criteria listed above plus the exclusion of other conditions that could result in hyperandrogenism or ovulatory dysfunction (such as a male hormone-producing tumor in the ovary or adrenal gland).  Because these findings may have multiple causes other than PCOS (hence the last criterion above), a careful, targeted medical history and physical examination are required to ensure appropriate diagnosis and treatment.

On physical exam, women suspected of having PCOS may have masculinizing signs, such as hirsutism, acne, and male-pattern hair loss.  On bimanual exam, they may have enlarged ovaries.  A transvaginal pelvic sonogram is done to assess the ovaries better, and if many follicles (20 or more in one ovary) are noted, a polycystic ovary (not necessarily PCOS) is diagnosed.

Women suspected of having PCOS should have baseline blood tests that check ovulation hormone and male and male-like hormone (androgen) levels and those that screen for type 2 diabetes, thyroid disease, and dyslipidemia (high blood levels of cholesterol and triglycerides). They should have their blood pressure taken to check for hypertension (high blood pressure).

Medical treatment of the signs and symptoms of PCOS is individualized based on the woman’s clinical presentation and desire for pregnancy.  Oral contraceptives (when not contraindicated) are typically used as the initial treatment for menstrual cycle irregularity, hirsutism, and acne in women who are not actively trying to get pregnant. Metformin is the first-line medication for metabolic manifestations, such as hyperglycemia. Clomiphene and letrozole are first-line medications for infertility.  Finally, other medications that may be used in the management of PCOS include:  anti-androgens, topical hair-removal agents, and topical acne agents.

Lifestyle management, such as by adopting calorie-restricted diet and exercise, is recommended for overweight women with PCOS.  Weight loss has been shown to have a positive effect on fertility and metabolic profile.

We at Adaptive Gynecology strive to motivate the women with PCOS in our practice to be an active part of the team approach to the management of PCOS. To ensure the best outcomes, we enlist the expertise of other, trusted medical colleagues who are also dedicated to helping women with PCOS.

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