Polycystic Ovary Syndrome (PCOS)
Often misdiagnosed and poorly understood, polycystic ovary syndrome (PCOS) is a lifelong disorder that can be managed with appropriate medical care. At Yale Medicine, our PCOS Program pulls together a team of specialists to address each aspect of this complex condition, providing guidance and medical intervention to meet every woman's specific needs.
"It's not one condition, it’s a spectrum and it has implications for your overall health," explains Lubna Pal, MD, director of the PCOS Program. "Menstrual irregularities and infertility, bothersome excess of facial and bodily hair, acne and even thinning of scalp hair are common presentations of this complex disorder. But these issues are controllable. PCOS-related infertility is easily fixable."
What is polycystic ovary syndrome (PCOS)?
PCOS is an umbrella term used to describe a collection of symptoms associated with certain classic hormone imbalances. Experts estimate that 5 to 10 percent of women ages 18 to 44 have PCOS. The syndrome is usually detected in women between ages 20 and 30, but the earliest signs can be evident in younger girls including those who have not yet started menstruation.
What are the symptoms of PCOS?
Menstrual irregularities (infrequent and irregular periods), excessive facial and bodily hair growth, acne and fertility problems are common symptoms of PCOS. Thinning of hair is another symptom experienced by some women with PCOS.
Approximately 50 percent of women in the U.S. with PCOS are obese and the condition puts women at a higher risk for type 2 diabetes, heart disease, ovarian cysts, obesity and infertility—and can lead to emotional distress.
What causes PCOS?
The exact cause of PCOS is unknown, but many women with the syndrome also have a mother or sister with it. And because women with PCOS are often overweight, researchers are studying the relationship between PCOS and the body's production of excess insulin, which can lead to symptoms associated with PCOS. Weight loss alone can improve many of the common symptoms (such as irregular menses, acne) of PCOS.
How is PCOS diagnosed?
While there is no single test to diagnose PCOS, it should be suspected in any woman experiencing the common symptoms and signs of PCOS. A combination of clinical presentation, pertinent blood tests and pelvic ultrasound examination are utilized for diagnosis.
"It’s a diagnosis of exclusion," Dr. Pal says. "Patients are frustrated that their doctor is not paying attention. Doctors are equally frustrated with the complexity of this disorder and find it easier to provide a diagnostic label of PCOS, rather than just stepping back and explaining the relationship between obesity and PCOS-related symptoms.”
If health care providers would take the time to better explain the "whats" and "whys" of the relationship between excess weight and a PCOS-like picture, and stress on the importance of weight loss and lifestyle modification to every woman presenting with symptoms of PCOS, "it is highly likely that many of the patients with PCOS will outgrow their PCOS diagnosis," Dr. Lubna says. "Counseling should cover not just the reasons for the symptoms, but should also include discussion on future implications for health and for fertility.”
What are the long-term risks of PCOS?
- Overall Health: Women with PCOS are likely to be overweight or obese, and over the course of their life are at risk for developing high blood pressure, abnormal cholesterol levels and diabetes. Emotional distress and symptoms of depression are also commonly seen in this population.
- Fertility: Disturbances in ovulation are a common cause of infertility in women with PCOS.
- Endometrial hyperplasia (a thickening of the uterine lining that can potentially lead to endometrial cancer): This risk while uncommon, is a particular concern for women with PCOS who are obese, diabetic or pre-diabetic and insulin resistant and who have a long history of menstrual irregularities.
How is PCOS treated?
There is currently no cure for PCOS. Management will differ depending on the most bothersome symptoms and on a woman’s desire to become pregnant. For women who are not seeking pregnancy, treatment will likely focus on correcting or harnessing the underlying hormonal imbalances.
It is important to understand that weight reduction and improvement in lifestyle are essential management strategies; weight loss alone can improve menstrual regularity as well as symptoms of acne and excess hair. Hormonal medications such as birth control pills are commonly used for managing menstrual irregularities, and to a lesser extent for management of acne and hair excess symptoms. Metformin, a common diabetes drug, is often utilized in PCOS management, particularly so in women who exhibit signs of insulin resistance or abnormalities in glucose control. Anti-androgens are utilized, often in combination with birth control pills, for women whose symptoms of hair excess and/or acne are not controlled with the use of birth control pill alone.
The Yale Medicine team will also help patients lose weight and manage any cosmetic concerns, such as facial hair. For the overweight to obese women who might want to become pregnant, the first line intervention will be weight loss.
Studies show that as many as 70 percent of women with PCOS have fertility problems. Women consult with a fertility expert to discuss treatment options, which may include common fertility medications such as clomiphene (Clomid), or the newer class of medications (aromatase inhibitors) that has shown better results in achieving ovulation in women with PCOS compared to clomiphene. Other options include advanced fertility treatments that utilize injectable hormones or intrauterine insemination. In vitro fertilization is recommended for some who either do not achieve pregnancy after three or more attempts at ovulation induction, or for women with PCOS who have additional contributors to infertility (such as problems with partner’s sperm or blocked tubes).
Are surgical options available?
The vast majority of women with PCOS can be managed with lifestyle modifications including attention to diet, exercise and weight loss and medical treatments. The surgical management option of “ovarian drilling” is uncommonly utilized for fertility seeking women who have tried and failed to achieve ovulation with use of clomiphene or aromatase inhibitors, and for whom use of injectable gonadotropin hormones is not an option (either due to financial or reasons or medical contraindications).
Ovarian drilling is a procedure where under laparoscopy, an electrically heated needle punctures the ovarian tissue and destroy tiny areas in each ovary. This procedure is followed by lowering of blood levels of testosterone, and spontaneous resumption of regular menses, although these benefits are unlikely to last beyond a few months.
What makes Yale Medicine's approach to PCOS stand out?
Yale Medicine's multidisciplinary team of experts will tackle each aspect of this complex disorder, offering consultation on metabolic needs, lifestyle modification, and, if needed, medical interventions.
Physicians at Yale Medicine are dedicated to helping girls and women with PCOS. The PCOS Program ensures that all aspects of a woman’s health, both physical and emotional, are assessed, and treatment approach is individualized to meet the needs of and reduce health risks for each patient. Choice of medical treatment takes into account the bothersome symptoms, the overall clinical picture and individualized risk profile of each patient. Also, an adolescent PCOS Program for patients as young as 12 is available to help craft age-specific symptom management plans.
In addition to addressing the hormonal and metabolic aspects of the disorder, we offer psychological counseling and support for women with PCOS, as well as for adolescents and their families who are trying to make sense of the disorder.