Polycystic Ovary Syndrome

By: Ervin E. Jones, MD, PhD, HCLD, FACOG
Genetics & IVF Institute

Polycystic ovary syndrome is the most common cause of infertility due to disorders of ovulation in reproductive age women. Abnormal menstrual cycle is often the earliest manifestation of ovulatory deficiency in these women. The fertility rate among women with polycystic ovary syndrome is approximately 2.5 fold less than that of normal reproductive age women. Polycystic ovary syndrome is also the most common endocrine disorder of the reproductive age woman and, therefore, carries considerable metabolic risk.

A syndrome is a constellation of symptoms and signs indicative of a disorder or disease. Polycystic ovary syndrome, as originally described by Stein and Leventhal in 1935, is a complex disorder of young women consisting of amenorrhea (lack of menstruation), hirsutism (increased hair growth) and obesity. There has been ongoing debate regarding the definition and diagnosis of polycystic ovary syndrome since it was originally described. The most widely used definition is the presence of excessive male hormones and irregular or complete absence of ovulation after exclusion of other known disorders. The Rotterdam consensus conference of 2003 characterized two types that are inclusive of the spectrum of this disorder. Type I polycystic ovary syndrome is described as the presence of excessive male hormones with polycystic ovaries and normal ovulation. Type II polycystic ovary syndrome is described as polycystic ovaries and irregular ovulation without evidence of excessive male hormones. Viewed differently, polycystic ovary syndrome can be defined as two subgroups of women with polycystic ovaries -- those with evidence of excessive male hormones who ovulate and those without evidence of excessive male hormones who do not ovulate. The presence of polycystic ovaries alone does not constitute polycystic ovary syndrome.

Polycystic ovary syndrome may also be an early manifestation of excessive insulin secretion that may cause cardiovascular and metabolic complications later in life. Polycystic ovaries can be detected in up to 70.4% of women reporting both abnormal growth of hair and abnormal or a complete lack of menstruation.

The diagnosis of polycystic ovary syndrome is primarily achieved through clinical history and physical findings. The principal features are increased hair growth or other biochemical evidence of excess male hormone production, which also includes acne, male pattern baldness and male pattern hair growth. Irregular menstrual bleeding is a key presentation in the infertile women with polycystic ovary syndrome.

Associated findings include insulin resistance, increased insulin secretion and obesity. On ultrasound, the ovaries may be enlarged and contain numerous small follicles arranged either in a chain bead pattern just beneath the surface or distributed throughout the substance of the ovary. Some investigators have also described abnormal blood flow to the ovaries in women with polycystic ovarian syndrome. Hormone tests will assist the physician in making the diagnosis. Over secretion of the pituitary hormones LH and FSH, which tell the ovary how to work, is a key finding in some, but not all, patients with polycystic ovary syndrome. Increased production of male hormones produced by the ovary is another cardinal finding in patients with polycystic ovarian syndrome. Measurements of glucose and insulin levels, as well as a lipid profile, are highly recommended in obese individuals.

Treatment must, obviously, depend on the desires of the individual patient. Women with polycystic ovary syndrome exhibit exaggerated responses to ovarian stimulation, abnormal egg development, implantation failure, and pregnancy loss. If the patient is concerned about menstrual irregularity and wishes to become pregnant, controlled ovarian stimulation with ovulation inducing drugs including clomiphene citrate, gonadotrophin or a combination of these combined with intrauterine insemination should be first line options for treatment. Clinical strategies that improve pregnancy outcome and minimize pregnancy loss in women with polycystic ovary syndrome must be sought. Correction of follicle growth to improve fertility, optimization of follicular responsiveness to gonadotropin therapy, and enhancement of pregnancy outcome either by controlled ovarian stimulation or in vitro fertilization must be the clinician's first goal.

With proper diagnosis and treatment, women with polycystic ovary syndrome may enjoy more regular menstrual cycles, overcome the troubling symptoms of the condition and become pregnant if they wish to have a baby.