PCOS

Consultant Gynaecologist Miss Meg Wilson talks about polycystic ovarian syndrome (PCOS) 

Polycystic ovarian syndrome (PCOS) is a common condition caused by a hormonal imbalance from the ovaries. The name itself is quite misleading as it implies the ovaries have lots of cysts when it is in fact multiple follicles that are seen on an ultrasound scan of the ovaries. Follicles are a normal part of the ovary however in ‘polycystic ovaries’ there are more on show and this makes the ovary larger than normal. These follicles have a cyst-like appearance but aren’t cysts at all. A more accurate name would be poly-follicular ovaries!

Having polycystic ovaries on its own isn’t enough to diagnose PCOS. Clinicians use the Rotterdam criteria, developed in 2003, to make the diagnosis. Women must have at least two out of three of the following issues:

• Appearance of polycystic ovaries on ultrasound scan
• A hormonal imbalance, where the testosterone levels are high on blood tests (hyperandrogenism)
• Irregular periods

These criteria are very broad and mean that a lot of women could have a PCOS diagnosis. This was addressed by the European Society for Human Reproduction and Embryology (ESHRE) in the summer of 2018. They have tried to help guide this diagnosis further with the following recommendations:

• Previously the number of cysts that needed to be seen on a scan was only 12; this has been increased to 20 due to the advancement of ultrasound images
• Women who are within 8 years of starting their periods should not have an ultrasound scan to diagnosed PCOS. This is because young women’s ovaries often have multiple follicles and can be wrongly diagnosed

There is a wide variation in the symptoms that women with PCOS may experience, and the help they need to address these, if they need help at all. The hormone imbalance can cause women to suffer with irregular periods, weight gain, acne and excessive body hair growth. This hormone imbalance links in with the body’s ability to manage sugar and some women also have insulin resistance or even type II diabetes.

Polycystic ovaries do not function as they should in a normal monthly cycle. Their follicles remain at a similar size all the time rather than developing one ‘dominant follicle’ for release of an egg (ovulation). This means that ovulation may be less frequent and more difficult to predict if you are trying to fall pregnant. Women with PCOS and irregular ovulation may require the tablet Clomid or Letrozole to help their ovaries ovulate so they can fall pregnant. This is different to in vitro fertilisation (IVF) treatment.

While there is often a stereotype of women with PCOS as overweight, the condition affects women of all shapes and sizes. Victoria Beckham and Jules Oliver, for example, are two famous women who have been vocal about having PCOS. Currently there is no ‘cure’ for PCOS; management of the symptoms is the main course of treatment, but plenty of people do not need help managing these symptoms.

For those women who are overweight, weight management is the cornerstone of symptom management; and sometimes it is possible to reverse the hormone imbalance completely through weight loss. In overweight women, losing as little as 5% weight can mean the ovaries start ovulating again and lessens other PCOS symptoms.

Weight loss is very difficult for most people. Fortunately, there are lots of support groups to help such as WW (Weight Watchers), Slimming World, and even groups on Facebook. Technology can also help women take control of weight loss, and we recommend apps such as MyFitnessPal, Sugar Smart, 7 Minute Workout, as well as wearables such as FitBit, pedometers or fitness trackers on your smartphone. It may be worth getting started with a personal trainer for an exercise plan and motivation, and you may also seek expert input from a dietician or nutritionist about an appropriate diet specific to women with PCOS.

Whilst weight control plays an important role in managing symptoms, some women are of a normal weight and still have symptoms. The oral contraceptive pill can help to regulate periods and often is a good treatment for acne and unwanted hair growth. There are many different forms of the pill and it is important that the one chosen contains a form of progesterone which is PCOS friendly. Some women may benefit from the drug Metformin to help with the hormonal imbalance and sugar control issues.

If desired, cosmetic hair removal treatments can be very effective; unwanted hair can be removed through treatments such as waxing, threading or laser. Doctors can prescribe a topical cream that can reduce hair growth on the face (Eflornithine). There are also anti-testosterone medications which can help with hair growth, but these are on prescription only and require monitoring from your doctor.

Finally, for anyone diagnosed with PCOS it’s important to consider the associated long-term health issues. Whilst some of these can be exacerbated by being overweight, all PCOS sufferers are at an increased risk of diabetes in pregnancy, insulin resistance and type II diabetes, cancer risks (endometrial cancer), cardiovascular issues, sleep issues and depression. Your doctor can help organise tests to check for these issues.

It may all sound like a poor outlook for women with PCOS, but we see many women who have empowered themselves to deal with their symptoms. They manage their symptoms effectively through an active healthy lifestyle, which feeds into a strong emotional wellbeing, and lead normal lives.