By Dr. Colin Michie FRCPCH University of Central Lancashire.
Challenges to having a baby cause understandable anxiety to a mother and her partner. One cause of infertility can be polycystic ovarian syndrome (PCOS) which affects 10-13% of women.
A family of hormones working in a balanced cycle maintain regular menstrual periods and fertility. If these hormones are disturbed over several months, follicles in the ovaries cannot release their eggs. The follicles then enlarge, becoming inflamed – they may be referred to as cysts. In some women, these problems are signs of a lifelong condition: Polycystic ovarian syndrome.
PCOS should be strongly suspected if a woman has irregular periods together with signs of high levels of male hormones or androgens. Raised androgens (such as testosterone) tend to cause acne and hair growth of a masculine pattern. This will become a cause of considerable worry. An ultrasound scan to look at the ovaries is helpful, but does not always assist – not all PCOS sufferers have cysts. Some women who do not have PCOS can have cysts for other reasons. Having obesity does not cause PCOS. However, about half of women with PCOS will gain weight.
Individuals with PCOS have abnormalities of other endocrine balances that cause a variety of symptoms. PCOS is commonly linked with an increased body weight in about half of patient groups, together with a resistance to insulin. This is type 2 diabetes. There is likely to be a risk of atherosclerosis and raised blood pressure; there may be sleep apnoea. Over time, these conditions pose a risk to heart health in younger sufferers of PCOS. Women with PCOS are the largest single group of adults at risk of developing cardiovascular disease and diabetes. Significant, too, are mental health associations with PCOS. These commonly include concerns about body image, anxiety and depression. PCOS causes the ovaries to become inflamed and that makes their eggs less viable and therefore less likely to be fertilised.
PCOS has collected several medical definitions, including sclerocystic ovaries, multicystic ovaries and Stein Leventhal Syndrome. Its exact effects on sufferers are still being described. Genetic analyses have found many genes contribute: None is linked to all women with PCOS. The condition can be inherited in some families. It can start in younger adolescents, where it may be seen as part of puberty. Some women with PCOS may conceive, but such pregnancies have a higher risk of preterm birth. PCOS often continues after the menopause.
Picture what this disorder means to an individual. The many impacts of PCOS on the quality of a woman’s life are high, so the disabilities it causes are similar to those in patients with malignancies or heart disease. PCOS differs widely between patients.
However, this year, evaluated managements, recommended by many different expert and patient groups, were published in November. PCOS care should ideally be personalised and holistic, combining counselling and mental health therapies (to set goals) alongside prescriptions. Lifestyle management, particularly encouraging exercise and improving diets has been found to be positive in most patients.
Menstrual irregularities and acne can improve with treatments with an oral contraceptive. A drug spironolactone is helpful in reducing the effects of androgens, reducing acne, blood pressure, hirsutism and cardiac risk. Some women have found spironolactone preferable to an oral contraceptive. The use of laser therapies for hair removal has psychological benefit. Bariatric surgery can be beneficial, improving menstrual problems, assisting with weight loss and improving insulin resistance.
For a woman trying to conceive, several treatments increase the chances of successful pregnancy by sensitising her cells to insulin. Metformin, inositol, pioglitazone and alpha-lipoic acid are safe medications that have these effects. They each have different advantages – for instance, metformin has several effects against diabetes; alpha-lipoic acid may reduce inflammation in the ovaries.
At present, we do not have a single marker or figure to measure the severity of PCOS: this is an area of active research in several countries. Guidance for patients as to the advantages and disadvantages of therapies alone or in combination is likely to be helpful.
In order to develop refined new strategies for successful pregnancies, more large-trials involving diverse groups of women, including those from Afro-Caribbean backgrounds, would be useful. PCOS is a common problem, for which new medications are available. Many sufferers await a formal diagnosis and often, as a consequence, use alternative health methods to help with their PCOS. In India, for instance, yoga and Ayurvedic approaches are known to be widely used for managing weight, stress and emotional well-being. These have not been found to improve fertility.
Polycystic ovarian syndrome remains unexplained. It is one of many challenges to fertility and health for which medical treatments are becoming increasingly effective.
Dr. Colin Michie is currently the Associate Dean for Research and Knowledge Exchange at the School of Medicine in the University of Central Lancashire. He specializes in paediatrics, nutrition, and immunology. Michie has worked in the UK, southern Africa and Gaza as a paediatrician and educator and was the associate Academic Dean for the American University of the Caribbean Medical School in Sint Maarten a few years ago.