A disturbing array of symptoms indicate PCOS, including acne, obesity and excess hair

Not a lot is known about the causes of polycystic ovarian syndrome (PCOS), but its symptoms are fairly telltale and include obesity, hirsutism (the medical name for excess face or body hair) acne and infertility. It's estimated that PCOS affects over five per cent of women in the UK and it has recently been associated with long-term risks of diabetes, heart disease and endometrial cancer.

As PCOS's name suggests, the syndrome is often (but not always) accompanied by ovaries enlarged with multiple small cysts. During the normal ovulation process, a hormone called follicle stimulating hormone (FSH) causes the release of an egg from an ovarian follicle, which then bursts from the follicle in the middle of the woman's menstrual cycle in response to another hormone, luteinising hormone (LH).

It is thought that in polycystic ovarian syndrome, male hormones or androgens somehow interfere with the levels of FSH and LH. This causes lots of follicles to form and no egg to be released from these follicles - whose appearance via an ultrasound is sometimes likened to a string of pearls - which forms the cysts observed in PCOS. >What causes it?
The exact cause of PCOS is unknown, although there is research into possible hereditary or genetic links. It is believed that the high levels of androgens appear as a result of abnormally high insulin levels. Produced by the pancreas, insulin is the hormone that regulates blood sugar levels. For some reason, in those women with PCOS, the cells around the body seem to become 'resistant' to insulin and so the pancreas makes more and more.

These high insulin levels send signals to the body to make more androgens, the so-called 'male' hormones, which include testosterone, and in turn causes multiple ovarian cysts, as well as obesity, acne and hirsutism.

When does it start?
For many, the syndrome starts around puberty, the first sign being irregular or absent periods. For others, PCOS symptoms may first become noticeable in the early 20s when acne or excess hair develops. The hormonal abnormalities of PCOS are possible even for women whose ovaries have been removed because androgens can be produced elsewhere in the body.

What are the symptoms?
Symptoms are varied and include:

• Irregular or absent periods. This is because a PCOS sufferer may be ovulating only infrequently, if at all.
• Infertility. Sometimes PCOS only comes to light when a woman seeks advice for infertility. Around 70 per cent of women who have problems conceiving because of abnormal ovulation also have PCOS.
• Obesity, oily skin or acne and hirsutism. These most visible symptoms of PCOS stem from excessive levels of androgens, which in women are produced in the ovaries, adrenal glands and in fat cells. Androgens are often called 'male hormones,' even though they are found in both men and women (they are usually present at much higher levels in men). Women with PCOS are more likely to gain weight and have more trouble losing it.
• Such symptoms alone are not enough to support a diagnosis of PCOS. They may only indicate 'hyperandrogenism,' which can be treated with anti-androgen medications.

How is it diagnosed?
There is no simple test. Your doctor will need to take a thorough history and physical examination, perhaps with some blood tests, to determine whether your symptoms are a result of PCOS. If he or she believes you have the condition you will be referred to a hospital specialist who may do further investigations.

Tests include:

• A look at your symptoms, especially a history of menstrual irregularities
• A physical examination, where your doctor will be looking for signs linked to high levels of testosterone, such as hirsutism, acne and obesity
• Blood tests. These will test level of androgens such as testosterone and the ratio of LH and FSH. A high ratio of LH to FSH, typically three-to-one, is characteristic of PCOS. These blood tests may also be used to rule out other conditions that give some similar symptoms, such as thyroid disease.
• An ultrasound scan, or a 'transvaginal scan,' where a small probe is inserted into the vagina to look for the characteristic picture of multiple cysts, is used but neither are definitive as it is very common for women without PCOS to have cysts. It is also common for women with PCOS to have no cysts. The ultrasound, however, can help confirm a diagnosis and examine the endometrial lining for abnormalities.

How is it treated?
There is, as yet, no one single cure for PCOS. Doctors usually address symptoms according to how troublesome they are. Factors include:

Obesity. Women with PCOS are more likely to be obese than other women, because the high levels of insulin mean that regulating the body's sugar levels - and therefore weight - proves more difficult. However, losing weight if you have PCOS will help regulate your periods and in turn makes you more likely to ovulate, reducing your risk of heart disease and lowering your insulin levels.

Hirsutism and acne. For some women, the most bothersome symptom is excess facial and/or body hair, often dark and coarse. This symptom, as well as acne and oily skin, is caused by overproduction of androgens. If it is mild, most women use cosmetic removal such as bleaching, waxing or electrolysis to remove the hair. But if not, drug therapy can reduce the affect of 'male' hormones, such as testosterone. For those women who do not wish to become pregnant, the most convenient treatment is the oral contraceptive pill, which reduces the effect of androgens.

In more serious cases, the diuretic drug, spironolactone (Aldactone) blocks the action of testosterone at the hair cell and can clear oily skin and also make unwanted hair finer. Flutamide, a newer drug similar to spironolactone, may have severe side effects but can be used by some. Bear in mind if you're trying to conceive that an anti-androgen medication cannot be used because it can cross the placenta and cause defects in a male foetus.

For acne, spironolactone and oral contraceptive pills (which decrease ovarian androgen production) can be used together, although other medications may be prescribed for acne, such as oral or topical antibiotics. A steroid such as dexamethasone may be prescribed if the primary source of excess androgens appears to be the adrenal glands. Because they are used at very low doses, they do not cause the usual side effects associated with steroids.

With all these treatments it can take up to nine months to see effects on hair growth, and a year to achieve peak effect. The hair will still be there, but will generally grow more slowly and will be lighter and finer.

Irregular or infrequent periods
Periods are essential for health: not only are they a good indicator of general health but the monthly shedding of the womb lining protects against uterine cancer. If irregular and/or infrequent menstruation is a problem, the combined oral contraceptive pill oestrogen and progestogen will probably be prescribed. A course of progestogen may be prescribed several times a year for women who are amenorrheic (having no periods) to induce periods. It is thought that having around six menstrual periods a year is enough to protect against uterine cancer.

Infertility
Infertility can be a consequence of PCOS. Many women with this condition are obese and the first line of treatment will be losing weight. Losing five per cent of your body weight may significantly increase your rate of ovulation.

The drug most used to increase fertility is an ovulation-stimulating drug called clomiphene citrate, known also as Clomid. Taken early in the menstrual cycle it induces ovulation in about 80 per cent of PCOS cases. If this is unsuccessful, injectable hormones may be used, but this increases the risk of multiple births, a risk greater with PCOS. Some women will choose to undergo in-vitro fertilisation (IVF) treatment if other methods don't work.

Newer approaches to treating PCOS include the use of insulin-sensitising drugs such as metforminulin. Studies suggest that these drugs may be useful to reduce levels of insulin in the future, especially in the regulation of periods and the treatment of infertility. At the moment, doctors are divided upon whether these drugs should be used and many are waiting for the results of further clinical trials.

Diabetes
PCOS is associated with insulin resistance and diabetes, but not all women who have PCOS are insulin-resistant or diabetic. If you have PCOS, you should also be regularly monitored for diabetes. This condition probably becomes more common in those with PCOS as they get older, affecting around one third of women, especially if they are overweight.

For more information contact: Verity, the Polycystic Ovaries Self Help Group,
52 Featherstone Street,
London EC1Y 8RT.
www.verity-pcos.org.uk.