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Polycystic Ovary Syndrome (PCOS)

Our guest expert in January 2011 was endocrinologist Dr. Sheila Laredo, a physician and an assistant professor in the department of medicine, division of endocrinology at the University of Toronto, as well as a clinical researcher at Women’s College Research Institute.

Dr. Laredo studies the treatment of polycystic ovary syndrome (PCOS). PCOS causes irregular menstrual cycles, excessive hair growth, infertility and other medical problems such as high blood pressure, abnormal cholesterol levels and increased risk of adult-onset diabetes.

Dr. Laredo has studied the role of diet and exercise in treating and controlling PCOS. She is interested in research that addresses the insulin resistance in PCOS, including diet, exercise, oral contraceptive use, and type of PCOS symptoms. She has trained many students, residents and fellows and has won teaching and research awards.

Here are her answers on Polycystic Ovary Syndrome (PCOS).

Q: What are the symptoms of PCOS?

A: PCOS is generally diagnosed according to what is referred to as the “Rotterdam” criteria (named for the conference where the criteria were developed). The Rotterdam criteria include the presence of at least two of the following three symptoms:

  1. irregular or absent ovulation (production and release of an egg from the ovary), based on the presence of irregular (generally infrequent) or absent menstrual periods
  2. evidence of excess male hormone effect either clinically (based on the presence of excess male-pattern hair, and sometimes male-pattern hair loss or adult acne) or biochemically (based on the presence of elevated male hormone levels in the blood) or both
  3. polycystic-appearing ovaries on ultrasound examination

In addition, other causes for these symptoms have to be excluded. This is usually done on the basis of a complete history and some blood testing.

These are the core symptoms of PCOS. There are additional associated medical conditions which are described in one of the answers below. 


Q: : What, if any, nutritional strategies are recommended when PCOS is suspected? 

A: First of all, I recommend that PCOS be definitively diagnosed. This is important because in many women with PCOS, lifestyle with modest weight reduction can be helpful in improving some of the symptoms. However, there are other conditions in which weight reduction can worsen the underlying condition. 

For women who have a normal body mass index (BMI), I recommend focusing on a healthy lifestyle including regular exercise and maintaining body weight. Many women with PCOS are thought to have underlying insulin resistance. Increasing exercise improves insulin resistance, even in the absence of weight loss. Thirty minutes of moderate aerobic exercise daily, at least five days per week, is probably sufficient to improve insulin sensitivity. 

In women who are overweight, there is evidence that weight loss of about 5-10 per cent (as an example, in a woman who weighs 200 pounds, this would be 10-20 pounds) can significantly increase menstrual frequency.

There is not currently enough evidence to indicate whether particular diets (e.g. low carbohydrate versus low fat) are more effective than other diets in women with PCOS. We are currently undertaking a study here at Women’s College Hospital to look at this more carefully.


Q: How does PCOS affect menopause and do symptoms subside once menopause has taken place?

A: This is a good question. Irregular periods are the easiest to recognize of the symptoms of PCOS, and they disappear with menopause. However, our current understanding indicates that irregular periods are caused by underlying insulin resistance, and this insulin resistance does not go away with menopause. Individuals with insulin resistance can be at greater risk of a number of other health conditions, and I generally monitor women with PCOS after menopause for these other conditions.

These conditions include: abnormal lipid (or cholesterol) levels, higher blood pressure, and higher risk of Type 2 diabetes. Women with PCOS are also at increased risk of fatty liver and sleep apnea, and are probably at higher risk for heart disease. All of these can be assessed and managed when identified. In particular, women with PCOS, even before menopause, have been shown to have a four- to five-fold increased risk for impaired glucose tolerance or Type 2 diabetes. I screen all of the women I see with PCOS with blood sugar testing initially, and then periodically (typically every two years) thereafter. Very often, a two-hour glucose tolerance test is needed, because a fasting blood sugar alone can fail to identify abnormal blood sugars in women with PCOS.


Q: I am wondering what health issues I should be concerned about as I age with PCOS? I’m taking Metformin which allowed me to ‘cycle’ enough to have four wonderful children. But should I be asking my doctor for any specific tests?

A: Metformin has been shown to increase the frequency of menstrual periods, and can be used in some women for this purpose. As reproductive issues become less of a concern and health issues become more of a concern, it is worthwhile to keep an eye on the medical issues listed in the previous question. I generally recommend a glucose tolerance test every two years, along with lipids (cholesterol), and an ALT (which is a screen, although an imperfect one, for fatty liver). We check blood pressure regularly in our clinic. I screen women with questions about their sleep (loud snoring, witnessed episodes during which breathing stops, awakening feeling unrefreshed, etc.), and recommend sleep testing for women who have some of these symptoms. There appears to be a higher risk of mood disorders in women with PCOS, so I screen for this as well.


Q: What can be done (besides using birth control pills) to minimize cyst growth and other symptoms of PCOS?

A: The word ‘cyst’ in the name ‘polycystic ovary syndrome’ is an unfortunate one, because in fact, women with PCOS do not have more cysts in their ovaries. What they have is a larger number of undeveloped follicles that are visible on ultrasound (although they appear as cysts because they are fluid-filled, they are not actually cysts). By definition, the ‘cysts’ (i.e. follicles) in PCOS ovaries are all less than one centimetre in size, and there must be at least a dozen of them visible in an ovary. Women (either with or without PCOS) can also have large ovarian cysts, but having one or more large ovarian cysts is not the same as having PCOS, and large ovarian cysts are managed differently than the ‘cysts’ seen in PCOS.

Because women with PCOS really have just visible follicles on ultrasound, the follicles by themselves do not require any specific treatment.

Treatment of other symptoms of PCOS really depends on the symptoms and on the woman’s individual needs at any given time. For example, treatment for women who just need their cycles more regular (in which birth control pills can be one of several useful options) would be different from treatment for women who are trying to conceive.


Q: I have read that obese women have a higher chance of ovarian cysts becoming cancerous. Is this the case if they are caused by PCOS? An article I read suggested that the ‘cysts’ from PCOS are not really cysts.

A: As the answer above indicates, you are correct that the ‘cysts’ in PCOS are not really cysts.  There is controversy, however, as to whether women with PCOS have a higher risk of ovarian cancer. Current thinking suggests that women with infertility may have a higher risk of ovarian cancer, particularly those who never conceive, although it isn’t clear whether this is related to the infertility, the treatment or something else. That said, the current research is by no means definitive; it is retrospective and based on relatively small numbers of women.


Q: Can I still have children if I have been diagnosed with PCOS?

A: Yes. There is a general misconception that women with PCOS cannot get pregnant, and I have seen many woman with PCOS have unplanned pregnancies because they did not think that contraception was necessary. These pregnancies may be diagnosed late, because women with PCOS are not always surprised when their period does not show up. 

The general population risk of infertility (often defined as the inability to conceive a pregnancy after 12 months of unprotected intercourse) is about 10-15 per cent, and also depends on age.  The risk of this is higher in women with PCOS when they have a higher BMI, and when they have very irregular or absent periods. The more regularly a woman with PCOS ovulates, the more likely she is to conceive. Not all women with PCOS who are having regular periods are ovulating, but this is fairly straightforward to test for using a simple blood test called progesterone.

In women with PCOS who are having difficulty conceiving, they and their partners should have a full medical evaluation. There can be other reasons that pregnancy is not occurring in addition to PCOS. There are also good treatment options available for women with PCOS who are not conceiving.


Q: I have PCOS and I have 3 daughters. I’m wondering how likely it is that they will inherit this condition. How early can we determine if they are affected?

A: This is also a good question. There is research that suggests that there is a genetic component to the development of PCOS, and approximately 30-40 per cent of mothers, daughters, or siblings of women with PCOS will also have PCOS. Some research suggests that girls who will go on to develop PCOS have an earlier onset of puberty, or even an earlier onset of “adrenarche.” Adrenarche is the increased activity of the adrenal glands that occurs before puberty. This is recognizable by the onset of body odor, pubic or underarm hair in a child/adolescent prior to puberty. The occurrence of adrenarche before the age of about eight in girls is considered early. Not all girls who have early adrenarche will necessarily develop PCOS, however.

Once girls have gone through puberty and had periods, there can be an interval of adjustment of approximately one year (some say two years) in which it is not unusual to have some irregular periods. If a girl is still having irregular periods beyond this time frame, and particularly if her mother has PCOS, I think it is quite reasonable to have her assessed by her health practitioner.


Q: What can someone with PCOS do to increase fertility?

A: The main barrier to fertility in women with PCOS, as compared to women who do not have PCOS, is the regularity of ovulation. Thus, the main thing that a woman can do for herself is lifestyle. As indicated earlier, in overweight women, weight loss can improve ovulation and cycle regularity, and this may lead to a higher likelihood of conceiving. It is prudent to ensure that there is no diabetes in a woman with PCOS prior to trying to conceive, since undiagnosed and untreated diabetes can adversely affect the ability to conceive, as well as the health of the pregnancy for both the mother and the fetus.  Of course, prenatal vitamins are recommended prior to attempting to conceive as well.

If the periods are not occurring relatively regularly, or if the periods are relatively regular but no pregnancy has occurred after about six months of trying to conceive in a woman who has PCOS, it is quite appropriate to seek medical help. There are a number of treatment options available. The first line treatment in women with PCOS is generally considered to be clomiphene citrate, which is a relatively safe and inexpensive oral medication, although treatment depends on the individual circumstances of a woman and her partner. There is an increased risk of multiple pregnancies (mostly twins, but more is possible) and other side-effects with this medication, so this should be carefully discussed with your health practitioner who is helping you to conceive.

Keep in mind that one of the most important determinants of fertility in women is age; this is the same for both women who have PCOS and those who do not.


Q: What is the relationship between PCOS and endometrial cancer, if any? And do oral contraceptives contribute to my risk?

A: Endometrial cancer is cancer of the lining of the uterus. This risk is increased in women who do not ovulate regularly, because progesterone (which is produced after ovulation) normally allows the lining of the uterus, or the endometrium, to mature and shed appropriately when there is no pregnancy. Women with PCOS who do not ovulate regularly are therefore at increased risk of the endometrium continuing to thicken, which can eventually lead to endometrial cancer. While there are no good studies to indicate how frequently menstrual periods should occur to protect women with PCOS from endometrial cancer, most practitioners feel that women with PCOS should get a “withdrawal” period at least every three months if they are not ovulating regularly.

Withdrawal bleeding can be achieved with the birth control pill (in this case the ‘withdrawal’ occurs every four weeks), or with oral progesterone pills given for several days. Typically, women will get menstrual bleeding after the progesterone is stopped. Progesterone can be given every three months, or more often if necessary. If metformin is used and women are having more frequent normal periods while taking it, this is also a reasonable strategy. Unlike oral contraceptives pills, neither progesterone alone nor metformin will prevent pregnancy (and may make pregnancy more likely).

Thus, to answer your question, oral contraceptives actually reduce the risk for endometrial cancer in women with PCOS who have infrequent periods.

An important note: women with excessively frequent, erratic or persistent spotting/bleeding should not consider this type of bleeding to be protecting them from endometrial cancer, and should be assessed by their health practitioner.


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