PCOS Diagnosis and Treatment
Polycystic ovarian syndrome (PCOS) is a relatively common cause of infertility being present in up to 20% of infertile women. The diagnosis of PCOS is established by oligomenorrhea (irregular ovulation), androgen excess (elevated male hormones such as testosterone or DHEAS), ultrasound evidence of polycystic ovaries (more than 12 small follicles on baseline ultrasound), or signs and symptoms such as acne or excessive facial or body hair consistent with elevated androgens.
Elevated androgens (typically thought of as male hormones) lead to many of the clinical manifestations of PCOS including increased body hair (hirsutism), menstrual irregularities, and if severe can lead to thinning of the hair on the scalp. Many women with PCOS are hyperinsulinemic meaning they have chronically elevated insulin levels. This is especially true if there is a family history of diabetes. Many women with PCOS are obese and find it very difficult to lose weight, even with caloric restrictions. However, thin women and those with “ideal body weights” can also have PCOS.
In many women, it is these elevated insulin levels that ultimately cause the over production of androgens by the ovary, which leads to ovulatory irregularities and the other symptoms of PCOS. Chronically elevated insulin levels can also lead to long term health consequences including increased incidence of cardiovascular disease, Type II diabetes (non-insulin dependent), and other conditions.
A reproductive endocrinologist, infertility specialist or an experienced gynecologist should manage PCOS patients attempting pregnancy. The disease is complex and there are many facets that must be considered. For example, PCOS patients can have an exaggerated, unpredictable response to FSH fertility drugs for ovulation induction.
PCOS is often treated with Clomid but most fertility specialists are now using Metformin (Glucophage) in conjunction with Clomid or as the “first line” treatment. Metformin belongs to a class of drugs termed “insulin sensitizing agents”. It lowers insulin levels by increasing the cells within the pancreas sensitivity to insulin. This increased sensitivity leads to lower insulin levels which reduces androgen production and allows normal ovulation to resume.
Fertility specialists will sometimes prescribe Metformin for “long term” treatment (not just for ovulation) hoping to avoid the ultimate health consequences of the disease. Sometimes Metformin is prescribed with Clomid or FSH. Letrozole (Femara) is a new, emerging treatment that is showing great promise for ovulation induction for PCOS patients. It has the advantage of less side effects and a lower risk of causing multiple gestations such as twins.
Surgery was once a common treatment for PCOS and involved removing sections of the ovary in an attempt to lower androgen production or “ovarian drilling”. Currently, surgery is rarely performed due to the effectiveness of treatments such as Metformin. If laparoscopic surgery is being performed for other indications, ovarian drilling could be considered in PCOS patients resistant to oral ovulation inducing drugs.
Infertility Causes
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