Polycystic ovary syndrome (PCOS): Everything there is to know!

Polycystic ovary syndrome, or PCOS, is the most common endocrine disorder in women of childbearing age. It is estimated to affect 1 in 10 women and is the leading cause of female infertility. It is estimated that 7 out of 10 women affected by PCOS are not diagnosed. 

The mechanisms at the origin of this disease are not yet understood, however, it is known that the condition is the result of a hormonal imbalance of ovarian and/or central (brain) origin which leads to an excessive production of androgens, hormones that allow the development of male physical characteristics, and are normally present in small quantities in women. 

Contrary to what the name of the disease might suggest, these are not cysts in the patient's ovaries but follicles filled with fluid or gas. 

What are the main symptoms and complications of PCOS?  

The intensity of the symptoms varies from person to person. The first symptoms may appear during the patient's first period, or much later.

The most common clinical signs of PCOS are: 

• Problems with ovulation, irregular, rare or absent periods, enlarged ovaries and difficulty conceiving. PCOS can cause the absence of ovulation, which results in the patient's inability to get pregnant. This means infertility, even though it is not always the case,
  
• Hyperandrogenism and hirsutism (abnormal hair growth), acne and alopecia,
  
• A metabolic disorder that makes the patient prone to abdominal obesity and hyperglycaemia and increases the risk of high blood pressure.
  

When at least two of these symptoms are present, PCOS can usually be confirmed.

Other symptoms may also lead to the diagnosis of PCOS: dark patches on the back of the neck, mood disorders, anxiety and sleep apnoea.

PCOS may cause complications in the long term. It increases the risk of developing metabolic syndrome, type 2 diabetes, cardiovascular diseases such as atherosclerosis or coronary heart disease, non-alcoholic fatty liver disease, endometrial cancer, cervical cancer and depression.

Moreover, if a woman affected with PCOS becomes pregnant, there is a high risk of complications during pregnancy, such as gestational diabetes, premature birth and pre-eclampsia. 

How is PCOS diagnosed? 

The diagnosis is based on hormonal assessment and, if necessary, abdominal and pelvic ultrasound.

A blood test is prescribed to carry out the hormonal assessment. It should be done between the 2nd and 5th day of the patient's menstrual cycle. For those who have stopped menstruating, menstruation is induced by means of a medication that includes progesterone, a female hormone that serves, among other things, to prepare the uterus for pregnancy.

The levels of the following hormones are measured:

• Follicle-stimulating hormone (FSH), which promotes the production of oestrogen, the development of follicles, and ovulation,
  
• Luteinising hormone (LH), which induces ovulation,
  
• Circulating testosterone, used to diagnose hyperandrogenism,
  
• Androstenedione, a hormone responsible for sexual differentiation and the development of male characteristics (deep voice, facial hair, etc.),
  
• Dehydroepiandrosterone sulphate (DHS), used to exclude the presence of an ovarian or adrenal tumour (tumour of the adrenal glands).
  

Depending on the case, other hormones, such as prolactin or TSH, may also be measured.

To complete the hormonal assessment, a metabolic assessment of blood sugar, insulin, cholesterol and triglycerides is also performed.

The abdominal and pelvic ultrasound can reveal an abnormally large number of small follicles in the ovaries (at least 20, when it should be between 5 and 10). However, this is not a decisive criterion in the diagnosis of PCOS. The clinical signs and biological symptoms alone are sufficient to establish the diagnosis.

How is PCOS treated?  

PCOS is a lifelong condition. Disease management is essential to prevent any long-term health risks. It includes treating the manifestations of the syndrome and preventing its complications until the menopause sets in.

The choice of treatment for polycystic ovary syndrome depends on the type and severity of the symptoms, the woman's age, and whether she plans on becoming pregnant.

The first approach concerns the patient's lifestyle, which should include regular physical activity and a well-balanced diet. In fact, if the patient is overweight, losing about 10% of her initial weight reduces hyperandrogenism, and is useful in treating amenorrhoea (absence of menstruation), and therefore, infertility.

Sport helps reduce the symptoms of anxiety and depression, and lose weight. However, weight loss is unlikely to benefit women with normal weight suffering with polycystic ovary syndrome.

The second approach to treating PCOS is based on drug treatment. Thus, hirsutism can be treated with an oestroprogestogenic pill (except if the woman is planning a pregnancy), in order to reduce the level of androgen. If there is a risk of cardiovascular disease, oral contraceptives are not prescribed. Other methods can also be effective: hair bleaching, electrolysis (electric hair removal), applying an eflornithine-based cream such as Vaniqa® to combat hirsutism, or taking spironolactone to block male hormones.

Acne is treated with topical creams and oral antibiotics.

Patients with type 2 diabetes take oral antidiabetics if the non-drug method is not sufficient to manage their blood glucose level. Metformin is often prescribed. If the woman does not wish to become pregnant, she may also be prescribed liraglutide (Victoza®) or Orlistat. These three drugs can be beneficial to patients who want to lose weight.

In order to treat infertility, it is necessary to ensure that other factors are not at the origin of the problem. Various treatments exist, such as ovarian stimulation using clomiphene citrate, such as Clomid®, ovarian drilling (also known as multiperforation, or laparoscopic ovarian diathermy), and in vitro fertilisation (IVF).

Today, researchers are still trying to identify the origin of the endocrine dysfunction, which is responsible for PCOS. Another challenge is to improve public and medical understanding of the syndrome, in order to ensure better screening, as it takes an average of 5 medical appointments to establish and confirm the diagnosis.