WHAT IS POLYCYSTIC OVARY SYNDROME?In PCOS ( Polycystic Ovarian Syndrome ), the levels of several hormones (LH (luteinizing hormone, the hormone that triggers ovulation), possibly testosterone, and sometimes insulin (the hormone that regulates blood sugar levels)) are elevated. The level of FSH (follicle-stimulating hormone), the hormone that causes the ovarian follicles to mature, is insufficient in PCOS to trigger the ovarian follicles to mature. With PCOS, ovulation, and therefore menstruation, stops for extended periods, and fertility is reduced. PCOS can also cause excess hair growth and/or acne and is often associated with obesity.
Treatment is necessary to induce ovulation and thus increase the chance of pregnancy. This can involve weight loss, tablets, injections, or laparoscopy. Losing weight often leads to spontaneous ovulation again, but also because PCOS can be linked to the development of cardiovascular disease, diabetes and possibly high blood pressure later in life, losing weight is recommended if you are overweight.WHAT IS PCOS?PCOS stands for polycystic ovary syndrome. This literally means that multiple (poly) fluid-filled sacs (cysts) are present in the ovary.HOW DOES PCOS DEVELOP?The cause of PCOS is unknown. It likely has more than one cause, and multiple hormones are involved. For example, there is often an increased level of LH (luteinizing hormone, the hormone that triggers ovulation), possibly an increased level of testosterone, and sometimes also an increased level of insulin (the hormone that regulates blood sugar levels), combined with an insufficient level of FSH (follicle-stimulating hormone, the hormone that stimulates the maturation of the follicles). This disrupts the maturation of the follicles. Consequently, multiple small, fluid-filled follicles are present in the ovary. These can usually be visualized with internal ultrasound.
Due to the impaired maturation of the follicles, ovulation often fails to occur and menstrual cycle irregularities occur. A normal menstrual cycle typically involves thirteen to fourteen menstrual periods per year; with PCOS, this occurs less than eight per year. The period between menstrual periods becomes longer than five to six weeks (oligomenorrhea) or menstruation stops for six months or longer (amenorrhea).WHO IS AFFECTED BY PCOS?PCOS affects 5 to 10 percent of all women. It runs in families. Obesity also plays a role. Women who are predisposed to PCOS develop PCOS when they gain weight. Because obesity is more common these days, PCOS may also become more common.
You may have PCOS if you have at least two of the following three characteristics:
- You have fewer than eight menstrual periods per year (oligomenorrhea), or menstruation stops altogether (amenorrhea) (see the normal cycle)
; - You have elevated testosterone levels and/or symptoms consistent with elevated testosterone levels, such as acne or excessive hair growth in a male pattern
; - More than twelve (poly)cystic (follicles) are seen in one or both ovaries during an internal ultrasound;HOW IS THE DIAGNOSIS MADE?Tests
To diagnose PCOS, blood tests and ultrasound examinations are usually performed. An internal ultrasound examination can be used to assess the ovaries for the presence of multiple follicles.
Blood tests Blood tests
are performed to determine the levels of FSH, LH, testosterone, estrogen, progesterone, and, if necessary, prolactin. This is usually performed ten days after a menstrual period, and may be repeated at a later date. If these levels are abnormal, further testing may be performed, including blood sugar (glucose) levels and possibly insulin and cholesterol.
Ultrasound
Normally, three to eight follicles (3-10 mm in diameter) are visible in each ovary by mid-cycle using internal ultrasound (see Ultrasound in Gynecology). In PCOS, more than ten to twelve follicles are often (but not always) visible in one or both ovaries.HOW IS PCOS TREATED?If you are overweight, your overall health is at risk, and losing weight is the first-choice treatment.
If your period has been absent for a long period, it may be wise to induce menstruation at least four times a year to shed the uterine lining. This reduces the risk of endometrial cancer. This can usually be achieved simply with the pill. You can discuss this with your doctor.
In the case of acne or excessive hair growth, the severity of the condition will influence whether or not to treat it.
If you want to become pregnant, various treatments are available, such as:
- Weight loss
- Tablets: clomiphene citrate
- Injections: gonadotropin
- Electrocoagulation of the ovaries: LEO
- Metformin.
These treatments are aimed at inducing ovulation every month. Inducing ovulation with tablets or injections is called ovulation induction.
Losing
weight is very important for overweight women. Often, the cycle then returns to normal, and ovulation occurs spontaneously. If you are being treated with tablets or injections, losing weight significantly increases your chances of pregnancy. Ask for support if you are unable to lose weight on your own. Your GP or gynecologist can also refer you to a dietitian. In addition to a healthy diet, sufficient exercise is also very important.
Clomiphene citrate:
Clomiphene citrate (Clomid) is recommended as the first medical treatment. After a period (spontaneous or medication-induced), take one or more tablets from the third to the seventh or from the fifth to the ninth day of your cycle. Ovulation occurs between approximately the thirteenth and twenty-first day of your cycle. The entire cycle then lasts no longer than 35 days.
How do you know if ovulation has occurred? There are several methods for this (see also OFO):
1. Monitoring the temperature during the cycle (BTC, basal temperature curve)
2. Around day 21 of the cycle, a blood test to measure progesterone levels
3. An internal ultrasound can be performed before and after ovulation
Chance of pregnancy
Approximately 80% of women ovulate during treatment with clomiphene citrate. More than half of these women become pregnant. The chance of a multiple pregnancy is slightly increased with clomiphene citrate (see IUI). If ovulation cannot be induced or if ovulation has been induced with Clomid in six to twelve ovulations without pregnancy, switching to a different treatment can be considered.
Side effects
Clomiphene citrate generally has few side effects. It can sometimes cause mood swings: you may feel emotional, angry more easily, or even depressed. Some women describe hot flashes as a side effect. If Clomid treatment doesn't induce ovulation, it's possible that your ovaries are insensitive to Clomid, a condition called Clomid resistance. In that case, the following treatments may induce ovulation:
Gonadotropin injections
. With this treatment, you'll receive injections of follicle-stimulating hormone (FSH) (produced in the laboratory, rFSH) or Human Menopausal Gonadotropin (HMG, produced from the urine of postmenopausal women) for several days. You can learn to administer the injections yourself, or your partner can learn to administer them under your skin.
You'll start the injections on the third day of your cycle. Your cycle is monitored with ultrasound scans; therefore, you should plan for multiple appointments. If ultrasound scans indicate that it's necessary, the doctor will adjust the dosage.
If one to a maximum of two or three follicles are sufficiently mature, you will receive an injection of human chorionic gonadotropin (HCG) to trigger ovulation. This injection is also subcutaneous. Ovulation occurs approximately 38-40 hours after this injection. The released egg is fertilizable for 8-12 hours. Sperm cells are viable for approximately 48-72 hours. Therefore, it is advisable to have intercourse within about 12 to 36 hours after the HCG injection.
Chance of Pregnancy:
With gonadotropins, ovulation is induced in approximately 90% of treatments. Pregnancy occurs in approximately half of these women.
Side Effects:
With gonadotropin treatment, there is a high chance that multiple follicles will mature simultaneously, increasing the risk of multiple pregnancies and also the risk of overstimulation (see OHSS). If ultrasound reveals more than two or three follicles larger than 15 mm, treatment will be discontinued. You are advised not to have sexual intercourse.
Laparoscopic ovarian electrocoagulation (LEO)
This treatment is performed using keyhole surgery (see Therapeutic laparoscopy) under general anesthesia. Several superficial small holes are burned in the ovaries. This changes the hormone production in the ovary and can cause ovulation.
Chance of pregnancy
The chance of pregnancy, including multiple pregnancies, is lower than with gonadotropin treatment. If you use Clomid or gonadotropins after LEO treatment, the chance is the same again.
Side effects
The surgery can cause adhesions around the ovaries. This sometimes prevents the egg from reaching the fallopian tube (see Fertility Surgery and Ectopic Pregnancy).
Metformin:
Metformin is a drug already used in the treatment of diabetes mellitus type II. It has recently become clear that some women with PCOS can only regulate their blood sugar metabolism by producing large amounts of insulin. The high insulin levels may lead to increased testosterone production and therefore disrupt ovulation. Metformin reduces insulin levels. Metformin appears particularly suitable for women who are overweight or have high insulin levels, but this treatment is currently still in research. Your doctor will discuss this with you.
Chance of Pregnancy:
The chance of pregnancy with Metformin treatment is not yet clear.
Side Effects
: Metformin may cause gastrointestinal complaints (nausea, vomiting, diarrhea, abdominal pain).
Alternative treatments:
If pregnancy does not occur after medication, IVF (in vitro fertilization) can be considered (see IVF). Women with PCOS have a higher risk of hyperstimulation during IVF (see OHSS).POSSIBLE CONSEQUENCES OF PCOSShort-term consequences
- Excessive hair growth
- Acne
- Reduced fertility
- Miscarriage
Excessive
hair growth Body hair is highly racially dependent. In women with PCOS, excess hair growth has a male pattern, for example, on the face, forearms, or in a line from the pubic hair up to the navel. You decide for yourself whether you want to have excess hair treated. Excessive hair growth depends primarily on the sensitivity of the hair follicle to testosterone. Testosterone levels can therefore be normal. Therefore, adequate treatment for excess hair growth is not always possible. Excessive hair growth can be treated with hormones (anti-androgens) or cosmetically.
Treatment with tablets
Cyproterone acetate is most commonly used. Cyproterone acetate is found in the Diane-35 pill, among other products. You should only expect significant results after at least six months of treatment. If you are taking cyproterone acetate, you must not become pregnant. This medication carries a risk of birth defects.
Cosmetic Treatment:
Cosmetic treatment may consist of simple plucking, shaving or waxing, electro-epilation, or laser hair removal. Discuss the options with your doctor and, if necessary, with a beautician or skin therapist. Laser hair removal is the newest and most effective treatment. However, only small areas can be treated. Often, only facial treatment is possible. Laser hair removal cannot be performed on darker skin tones. Laser treatment is not (yet) or only
partially reimbursed.
Acne:
Adult acne is more common in women with PCOS. Acne can be significantly reduced with the use of Diane-35 or another pill. If this does not provide sufficient results, a referral to a dermatologist may be necessary.
Reduced Fertility:
Due to a reduced number of ovulating cycles, PCOS patients have a greater chance of a reduced chance of pregnancy. Therefore, it will generally take longer to conceive. The chance of pregnancy depends heavily on the average number of ovulating cycles you have. Women who become
pregnant
after treatment for PCOS have a slightly higher risk of miscarriage. This cannot be influenced (see Vaginal bleeding in the first few months of pregnancy).
Long-term consequences.
Consequences for general health.
Women with PCOS may have an increased risk of developing health problems later in life. These problems usually only arise around or after menopause. These include type II diabetes mellitus, cardiovascular disease, high blood pressure, and an increased risk of endometrial cancer at a young age. Many of these problems are associated with excess weight and reduced insulin sensitivity. Early detection and treatment of these problems can reduce their long-term consequences.
Diabetes mellitus (type II):
Approximately half of women with PCOS are overweight. Excess weight is often associated with reduced insulin sensitivity. To maintain normal blood glucose levels, more insulin is produced. If blood glucose levels remain too high, sugar metabolism is disrupted, ultimately leading to diabetes mellitus type II.
High blood pressure, elevated cholesterol, and cardiovascular disease:
Excess weight, high testosterone, and diabetes increase the risk of high blood pressure, elevated cholesterol, and cardiovascular disease. Treating these problems through weight loss, diet, increased exercise, and, if necessary, medication reduces the risk of damage to your body. Your doctor can help you with this.FINALLYPCOS can have a significant impact on your life. Uncertainty about whether you will be able to conceive, the challenge of losing weight, the many hospital visits during treatment, the possible need for hormone therapy, and the frequent disappointment of unsuccessful treatment can all be emotionally draining. Discuss your feelings with your partner, close friends, family, and possibly at work. Excess
hair, acne, and being overweight can also be difficult to cope with. Often, these problems are not treated satisfactorily, and your social life can be affected. Support from a doctor, psychologist, dietitian, and/or beautician, as well as connecting with others in the same situation, can be helpful.
Finances:
Consult with your health insurer to determine whether the proposed treatment is covered. This varies by plan and insurer. |
