Polycystic Ovarian Disease (PCOS)
Polycystic ovarian syndrome (PCOS) is a relatively common hormonal disorder in women that causes irregular or absent ovulation. It is estimated that 20% of infertile women have PCOS.
The ovaries of women with PCOS typically develop numerous small cystic follicles which do not develop properly. They have chronically elevated levels of androgens (male hormones; testosterone) and resistance to insulin. They typically have hirsutism (excess body hair), are overweight (thin women can have PCOS), have a greater chance of developing diabetes, and present with a classic “pear shaped” body appearance.
Chronically elevated insulin levels lead to the overproduction of androgens by the ovaries, and to a decrease in serum sex hormone-binding globulin leading to an increase in testosterone. Elevated testosterone causes the classic symptoms of PCOS.
Patients with suspected PCOS should be seen by a reproductive endocrinologist as this is a complex disease with many treatments. PCOS is often misdiagnosed unless a complete infertility evaluation is performed. Typical blood tests include an FSH, LH, prolactin, thyroid hormone, and fasting glucose and insulin level.
Clomid is often used as a first line treatment for women with PCOS. The starting dose is 50 mg per day on cycle days 3-7. In the first cycle, a progesterone level is drawn on cycle day 21 to test for ovulation. If the level is > 5, the same dose is continued and the patient is encouraged to begin using ovulation detection kits. If the progesterone level is low, menses is induced with Provera and the dose is increased to 2 or 3 tablets a day.
Virtually all Clomid pregnancies occur in the first 4-6 months of use. Typical side effects include hot flashes, mood swings, and vaginal dryness. Headaches and visual changes are rare. The chance of having twins on Clomid is approximately 8-10% and the triplet rate is less than 1%.
Metformin is often used to induce ovulation in PCOS patients if the patient is insulin resistant. Metformin sensitizes cells to insulin and corrects hyperinsulinemia thus reducing androgen production by the ovaries and enabling ovulation. If metformin alone is not effective, Clomid is often added. Other less common treatments for PCOS are “ovarian drilling” by laparoscopy and a new medicine, Femara.
PCOS is often treated with injectable follicle stimulating hormone and these patients typically have an exaggerated response with the production of multiple eggs. The main concerns with this treatment are cost (the medicines are expensive) and multiple birth rate (30% twins; 5% triplets; <1% quadruplets or greater). Frequent monitoring is needed to guide the treatment.
Weight reduction will sometimes restore ovulation in obese patients; however, it is very difficult for PCOS patients to loose weight. If body weight is reduced, it is also difficult to maintain due to a variety of reasons. While the best diet has not been determined, a low carbohydrate approach works well with many of these patients. Women who are interested in weight loss should discuss these issues with a reputable organization such as “Weight Watchers” or talk with a nutritionist.