>Fat, hairy, spotty and infertile - polycystic ovarian syndrome sufferers are the Cinderellas of gynaecology. Dr Gillian Lockwood offers remedies that work

What is PCOS and how can I tell if I have it?
One in five of all women have polycystic ovaries, but only a small proportion of these women will suffer from true Polycystic Ovarian Syndrome (PCOS). Women with PCOS can get fat and spotty and sad, and find it difficult to get pregnant. They sometimes comfort eat, only to find that their doctors tell them it's their fault and they should lose weight.

The good news is that PCOS is the only weight problem that is entirely due to a hormonal imbalance (and not just an inability to stay out of the fridge).

Polycystic Ovarian Syndrome (PCOS) is diagnosed by ultrasound scan of the ovaries and is defined as enlarged ovaries with more than 10 cysts around the edge. Hormone imbalances characteristic of PCOS can lead to irregular periods, brown patches on the skin, obesity, acne and excess facial or body hair growth. In the most severe cases sufferers may experience male-pattern hair loss and voice changes due to excess testosterone.

Most women with polycystic ovaries will not have any significant problems conceiving. A minority will experience delayed conception, a higher miscarriage rate and more complicated pregnancies.

Taking PCOS seriously
Young women with irregular periods often go to the doctor and, without further investigation, are put on the Pill. The resulting regular 'periods' may mask an underlying case of PCOS. This only becomes evident when women come off the Pill to try for a pregnancy, and find that their periods are as infrequent and unpredictable as they were before.

Even if women are not actively trying to get pregnant, they must recognise that PCOS is a life-long diagnosis and, for the sake of their general health, they must take their PCOS seriously.

Women with PCOS are at increased risk of health problems related to obesity such as diabetes and hypertension (high blood pressure). They can hypersecrete insulin (the sugar-processing hormone) and this can make them gain weight that is very difficult to lose.

It is vital to recognise that achieving a normal Body Mass Index (BMI) will not only help them achieve a spontaneous pregnancy, but will also increase the chance of fertility treatment working.

A normal maximum BMI for a woman who is 5 foot is 10 stone. If she is 5 ft 6in the maximum is 12 stone. PCOS runs in families through the female line and so asking sisters, aunts and mums about their fertility history may be very revealing. The ideal diet for a woman with PCOS is very low in fat and high in fibre and she should combine this with an active exercise regime.

Treatments that work
Anti-oestrogens
Absent or irregular ovulation associated with PCOS should first be treated with anti-oestrogens (clomiphene or tamoxifen). With clomiphene (Clomid), treatment begins on the second day of a spontaneous or induced period at a dose of 50-100 mg per day and continues for five days. Clomiphene treatment can be started by your GP or by a hospital fertility specialist. You should be offered an ultrasound scan in your first cycle to check you are not over-responding (the chance of having twins with clomiphene therapy is raised by 10 per cent).

While ovulation occurs in about 80 per cent of women taking clomiphene, pregnancy occurs in only about 40 per cent. If pregnancy does not occur within the first six cycles of treatment, you must be checked for male factor infertility (a sperm test) and tubal factor infertility (a laparoscopy or hysterosalpingogram or HSG).

Tamoxifen is taken at a dose of 20-40mg from days two to six. Side effects of clomiphene and tamoxifen include visual disturbance (if this occurs, treatment should be stopped immediately), multiple pregnancy, abdominal distension, ovarian cysts, hot flushes, dizziness and nausea.

Gonadotropin therapy
Gonadotropin therapy (FSH hormone injection) is indicated for women with PCOS who have been treated with anti-oestrogens and who fail to ovulate, show persistent hyper-secretion of luteinising hormone (LH) or have a negative post-coital test. LH is released from the pituitary gland, which causes the egg to pop out of the follicle. Women with PCOS have relatively high levels of LH and this may be related to their higher rate of miscarriage.

A post-coital test is carried out to see how well a woman's partner's sperm survives in her cervical mucus. She has to come to the clinic shortly after intercourse, and a sample of cervical mucus is examined under the microscope to check for the presence or absence of active sperm. It is unreliable and embarrassing and rapidly falling out of favour.

Gonadotropin treatment involves the woman taking a daily injection of FSH (follicle stimulating hormone-75-150 international units) and having regular ultrasound scans to monitor the development of the follicles (the little egg-containing sacs on the ovary).

When two or three follicles 16-20 mm in diameter are visible on ultrasound, ovulation should be triggered with an injection of hCG (human chorionic gonadotropin). The egg (or eggs) will be released about 35 hours later so the couple should have intercourse before then (or IUI - intra-uterine insemination - can be performed).

Laparoscopic ovarian diathermy
Laparoscopic ovarian diathermy (LOD) is a surgical treatment for PCOS, which is offered to women with clomiphene-resistant PCOS. It involves applying a short burst of diathermy (heat) or laser treatment to the surface of each ovary at multiple points. The hormone changes that this induces encourage the ovaries to ovulate spontaneously.

The laparoscopy is like a miniature telescope with a fibre optic system that is inserted through keyhole surgery into the abdomen, to examine the cavity, ovaries, outside of the tubes and the uterus.

It is free of the risks of ovarian hyperstimulation and multiple pregnancy and does not require intensive ultrasound monitoring.

Hyperstimulation is a condition that occurs in two to five per cent of fertility treatment cycles. The ovaries 'over-respond' to the stimulating drugs and produce large numbers of follicles and this can cause abdominal swelling, pain, nausea and breathlessness. If pregnancy occurs then the woman can require hospitalisation for pain control and drainage of excess fluid from the abdomen.

LOD also offers an opportunity to check that the Fallopian tubes are healthy as a dye insufflation test can be performed at the same time as the LOD. This is when a blue dye is introduced through the cervix into the uterus. It then travels through the Fallopian tubes and rapidly emerges at the open end near the ovaries. If the tubes swell or the dye fails to come out, then it is likely the tubes are blocked.

Approximately 60% of women with PCOS will have regular, ovular cycles after LOD and these may last for six to nine months during which time pregnancy should occur if there are no other fertility problems.

A successful outcome
If a woman with PCOS fails to achieve a pregnancy after she has tried clomiphene, LOD and gonadotropins, she may choose to try IVF. In spite of the many problems associated with PCOS, it is nevertheless one of the most successfully treated infertility diagnoses, and women with PCOS can be reassured that they are very likely to achieve a successful pregnancy.