What is Polycystic Ovary Syndrome (PCOS)?

Polycystic Ovary Syndrome (PCOS) is the most common female hormonal disorder affecting 6-10% of all reproductive-aged women. Despite being the most prevalent reproductive hormonal disorder, the management of PCOS continues to be evasive but there is a treatment for PCOS. There is unexplained abnormal synchrony from the brain to the ovaries that causes an increase in male hormone (testosterone) and lack of ovulation.

In addition to having the reproductive health risks of abnormal uterine bleeding, ovulation dysfunction with subsequent infertility, and endometrial hyperplasia with risks of pre-cancer, PCOS patients show a higher prevalence for metabolic syndrome (abdominal obesity, abnormal lipids, high blood pressure, and pre-diabetes).

To be diagnosed with PCOS, a patient typically has two of the following criteria:

  • Ovulation dysfunction
  • Irregular or abnormal menstrual intervals
  • Unwanted hair growth (in a male pattern) or elevated blood testosterone levels
  • The appearance of polycystic ovaries in an ultrasound

Other signs and symptoms of PCOS may include:

  • Acne
  • Pelvic pain
  • Difficulty getting pregnant
  • Patches of thick, dark, velvety skin

What is the Best Treatment for PCOS?

The treatment for PCOS is based on the primary needs and interest of the patient. For some women, pregnancy will be the motivating factor. For others, it might be control of abnormal uterine bleeding. There are two categories of risks with PCOS:

Abnormal menstrual intervals Elevated body mass index
Infertility from ovulation dysfunction Pre-diabetes/diabetes
Gestational diabetes (during pregnancy) Unwanted hair growth
Possible higher miscarriage Elevated blood pressure, cholesterol
Pre-uterine cancer

Any medical abnormality or risk needs to be addressed before a patient can consider getting pregnant. For pregnancy, we recommend an optimal body weight. Ovulation induction can occur with oral medication, the most effective of which is letrozole, particularly in overweight women. Other options include surgery on the ovaries (ovarian drilling) and in-vitro fertilization (IVF).

Many studies have suggested the non-FDA-approved usage of metformin will improve ovulation function in PCOS patients, along with decreasing the miscarriage rate and the development of gestational (“in-pregnancy”) diabetes. Initial enthusiasm for metformin in infertility PCOS patients has waned as the available evidence is inconsistent regarding its benefit, particularly in those trying to conceive. As with many medical therapies, “one size does not fit all,” and there appears to be a more select patient population that may benefit from metformin.

The second ESHRE/ASRM-sponsored PCOS Consensus Workshop Group in 2007 concluded that clomiphene citrate is the first-line agent for ovulation induction, followed by gonadotropins or laparoscopic ovarian diathermy. The expert panel confirmed that metformin should be limited to PCOS pre-diabetes patients with prediabetes, as the current evidence does not support the routine use of metformin for inducing ovulation.

Therefore, metformin may benefit women with prediabetes, clomiphene resistance or prior miscarriage, and those undergoing IVF to potentially improve embryo quality and reduce the risk of ovarian hyperstimulation syndrome. Unfortunately, the debate continues as to which infertility PCOS patients, if any, will gain from metformin.

Letrozole, though an off-label indication, has also been used as second-line therapy for ovulation induction, and recently has been shown to be more effective than clomiphene citrate, particularly in overweight women.

What are some helpful PCOS resources? 

Check out these resources from EndocrineWeb.com for additional PCOS resources: