Polycystic ovary syndrome (PCOS) is a common endocrine system disorder among women of reproductive age. Women with PCOS may have enlarged ovaries that contain small collections of fluid — called follicles — located in each ovary as seen during an ultrasound exam.
Infrequent or prolonged menstrual periods, excess hair growth, acne, and obesity can all occur in women with polycystic ovary syndrome. In adolescents, infrequent or absent menstruation may raise suspicion for the condition.
The exact cause of polycystic ovary syndrome is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications, such as type 2 diabetes and heart disease.
Polycystic ovary syndrome signs and symptoms often begin soon after a woman first begins having periods (menarche). In some cases, PCOS develops later during the reproductive years, for instance, in response to substantial weight gain.
PCOS has many signs — things you or your doctor can see or measure — and symptoms — things that you notice or feel. All of these can worsen with obesity. Every woman with PCOS may be affected a little differently.
To be diagnosed with the condition, your doctor looks for at least two of the following:
- Irregular periods. This is the most common characteristic. Examples include menstrual intervals longer than 35 days; fewer than eight menstrual cycles a year; failure to menstruate for four months or longer; and prolonged periods that may be scant or heavy.
- Excess androgen. Elevated levels of male hormones (androgens) may result in physical signs, such as excess facial and body hair (hirsutism), adult acne or severe adolescent acne, and male-pattern baldness (androgenic alopecia).
- Polycystic ovaries. Polycystic ovaries become enlarged and contain numerous small fluid-filled sacs which surround the eggs.
When to see a doctor
See your doctor if you have concerns about your menstrual periods, if you're experiencing infertility or if you have signs of androgen excess such as acne and male-pattern hair growth.
Doctors don't know what causes polycystic ovary syndrome, but these factors may play a role:
- Excess insulin. Insulin is the hormone produced in the pancreas that allows cells to use sugar (glucose) — your body's primary energy supply. If you have insulin resistance, your ability to use insulin effectively is impaired, and your pancreas has to secrete more insulin to make glucose available to cells. Excess insulin might also affect the ovaries by increasing androgen production, which may interfere with the ovaries' ability to ovulate.
- Low-grade inflammation. Your body's white blood cells produce substances to fight infection in a response called inflammation. Research has shown that women with PCOS have low-grade inflammation and that this type of low-grade inflammation stimulates polycystic ovaries to produce androgens.
- Heredity. If your mother or sister has PCOS, you might have a greater chance of having it, too. Researchers also are looking into the possibility that certain genes are linked to PCOS.
Having polycystic ovary syndrome may make the following conditions more likely, especially if obesity also is a factor:
- Type 2 diabetes
- High blood pressure
- Cholesterol and lipid abnormalities, such as elevated triglycerides or low high-density lipoprotein (HDL) cholesterol, the "good" cholesterol
- Metabolic syndrome — a cluster of signs and symptoms that indicate a significantly increased risk of cardiovascular disease
- Nonalcoholic steatohepatitis — a severe liver inflammation caused by fat accumulation in the liver
- Sleep apnea
- Depression and anxiety
- Abnormal uterine bleeding
- Cancer of the uterine lining (endometrial cancer), caused by exposure to continuous high levels of estrogen
- Gestational diabetes or pregnancy-induced high blood pressure
For polycystic ovary syndrome, you might first see your family doctor or primary care provider. However, you may be referred to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist), one who specializes in hormone disorders (endocrinologist) or one who specializes in treating infertility (reproductive endocrinologist).
What you can do
To prepare for your appointment:
- Write down any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
- Make a list of medications, vitamins and dietary supplements you take. Write down doses and how often you take them.
- Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
- Bring a notepad or electronic device with you to take notes. Use it to record important information during your visit.
- Think about what questions you'll ask. Write them down so that you won't forget important points you want to discuss with your doctor.
For polycystic ovary syndrome, some basic questions to ask include:
- What kinds of tests might I need?
- How does this condition affect my ability to become pregnant?
- Are medications available that might improve my symptoms or my ability to conceive?
- I have other medical conditions. How can I best manage them together?
- What side effects can I expect from medication use?
- What treatment do you recommend for my situation?
- What are the long-term health implications of PCOS?
- Do you have any brochures or other printed materials that I can take with me?
- What websites do you recommend visiting?
Don't hesitate to ask your doctor to repeat information or to ask follow-up questions for clarification.
What to expect from your doctor
Some potential questions your doctor or health care provider might ask include:
- What signs and symptoms are you experiencing?
- When did each symptom begin?
- Have you had symptoms since you first started having periods?
- How often do you experience these symptoms?
- How long have you been experiencing symptoms?
- How severe are your symptoms?
- When was your last period?
- Have you gained weight since you first started having periods? How much weight have you gained? When did you gain the weight?
- Does anything improve your symptoms?
- Does anything make your symptoms worse?
- Are you trying to become pregnant, or do you wish to become pregnant?
- Has your mother or sister ever been diagnosed with PCOS?
There's no specific test to definitively diagnose polycystic ovary syndrome. The diagnosis is one of exclusion, which means your doctor considers all of your signs and symptoms and then rules out other possible disorders.
During this process, you and your doctor will discuss your medical history, including your menstrual periods, weight changes and other symptoms. Your doctor may also perform certain tests and exams:
- Physical exam. During your physical exam, your doctor will note several key pieces of information, including your height, weight and blood pressure.
- Pelvic exam. During a pelvic exam, your doctor visually and manually inspects your reproductive organs for signs of masses, growths or other abnormalities.
- Blood tests. Your blood may be drawn to measure the levels of several hormones to exclude possible causes of menstrual abnormalities or androgen excess that mimic PCOS. Additional blood testing may include fasting cholesterol and triglyceride levels and a glucose tolerance test, in which glucose levels are measured while fasting and after drinking a glucose-containing beverage.
- Ultrasound. An ultrasound exam can show the appearance of your ovaries and the thickness of the lining of your uterus. During the test, you lie on a bed or examining table while a wand-like device (transducer) is placed in your vagina (transvaginal ultrasound). The transducer emits inaudible sound waves that are translated into images on a computer screen.
Polycystic ovary syndrome treatment generally focuses on management of your individual main concerns, such as infertility, hirsutism, acne or obesity.
As a first step, your doctor may recommend weight loss through a low-calorie diet combined with moderate exercise activities. Even a modest reduction in your weight — for instance, losing 5 percent of your body weight — might improve your condition.
Your doctor may prescribe a medication to:
Regulate your menstrual cycle. To regulate your menstrual cycle, your doctor may recommend combination birth control pills — pills that contain both estrogen and progestin. These birth control pills decrease androgen production and give your body a break from the effects of continuous estrogen, lowering your risk of endometrial cancer and correcting abnormal bleeding. As an alternative to birth control pills, you might use a skin patch or vaginal ring that contains a combination of estrogen and progestin. During the time that you take this medication to relieve your symptoms, you won't be able to conceive.
If you're not a good candidate for combination birth control pills, an alternative approach is to take progesterone for 10 to 14 days every one to two months. This type of progesterone therapy regulates your periods and offers protection against endometrial cancer, but it doesn't improve androgen levels and it won't prevent pregnancy. The progestin-only minipill or progestin-containing intrauterine device are better choices if you also wish to avoid pregnancy.
Your doctor also may prescribe metformin (Glucophage, Fortamet, others), an oral medication for type 2 diabetes that improves insulin resistance and lowers insulin levels. This drug may help with ovulation and lead to regular menstrual cycles. Metformin also slows the progression to type 2 diabetes if you already have prediabetes and aids in weight loss if you also follow a diet and an exercise program.
Help you ovulate. If you're trying to become pregnant, you may need a medication to help you ovulate. Clomiphene (Clomid, Serophene) is an oral anti-estrogen medication that you take in the first part of your menstrual cycle. If clomiphene alone isn't effective, your doctor may add metformin to help induce ovulation.
If you don't become pregnant using clomiphene and metformin, your doctor may recommend using gonadotropins — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) medications that are administered by injection. Another medication that your doctor may have you try is letrozole (Femara). Doctors don't know exactly how letrozole works to stimulate the ovaries, but it may help with ovulation when other medications fail.
When taking any type of medication to help you ovulate, it's important that you work with a reproductive specialist and have regular ultrasounds to monitor your progress and avoid problems.
- Reduce excessive hair growth. Your doctor may recommend birth control pills to decrease androgen production, or another medication called spironolactone (Aldactone) that blocks the effects of androgens on the skin. Because spironolactone can cause birth defects, effective contraception is required when using the drug, and it's not recommended if you're pregnant or planning to become pregnant. Eflornithine (Vaniqa) is another medication possibility; the cream slows facial hair growth in women.
To help offset the effects of PCOS:
- Keep your weight in check. Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels and may restore ovulation. No single specific dietary approach is best, but losing weight by reducing how many calories you consume each day may help with polycystic ovary syndrome, especially if you're overweight or obese. Use smaller plates, reduce portion sizes and resist the urge for seconds to help with weight loss. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian for help in reaching weight-loss goals.
- Consider dietary changes. Low-fat, high-carbohydrate diets may increase insulin levels, so you may want to consider a low-carbohydrate diet if you have PCOS — and if your doctor recommends it. Don't severely restrict carbohydrates; instead, choose complex carbohydrates, which are high in fiber. The more fiber in a food, the more slowly it's digested and the more slowly your blood sugar levels rise. High-fiber carbohydrates include whole-grain breads and cereals, whole-wheat pasta, bulgur wheat, barley, brown rice, and beans. Limit less healthy, simple carbohydrates such as soda, excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.
- Be active. Exercise helps lower blood sugar levels. If you have PCOS, increasing your daily activity and participating in a regular exercise program may treat or even prevent insulin resistance and help you keep your weight under control.