Polycystic ovary syndrome (PCOS) – causes, symptoms and treatment

What is polycystic ovary syndrome?

Polycystic ovary syndrome – PCOS for short – is the most common hormonal disorder among women of childbearing age. It is one of the main causes of menstrual irregularities and infertility. The condition often manifests as numerous small cysts in the ovaries. These are referred to as ‘polycystic ovaries’. Such changes occur in around 20 per cent of women of childbearing age, but are not always associated with symptoms or discomfort. The symptoms of PCOS are triggered by a hormonal imbalance. The following hormones play a key role in this:

• Oestrogen (female sex hormone)
• Androgens (male sex hormones)
• LH (luteinising hormone)
• FSH (follicle-stimulating hormone)

Androgens, in particular, are usually overproduced, which is why male-pattern body hair is a typical symptom of PCOS. Many women with PCOS have androgen levels twice as high as those of women without the condition. The hormonal imbalance of the sex hormones contributes to ovulation disorders. As a result, periods may be irregular or stop altogether. This often reduces fertility. In addition, many women with PCOS develop insulin resistance. The insulin receptors no longer respond adequately to the insulin released. This leads to a metabolic state similar to that seen in type 2 diabetes. PCOS can occur in fertile women of any age, but is often first noticed in late adolescence. Worldwide, up to eight per cent of all women are affected by this complex hormonal condition. PCOS is also often associated with depression and anxiety disorders.

What are the causes and risk factors for PCOS?

The exact causes of polycystic ovary syndrome are not yet fully understood. However, as the condition runs in some families, a genetic predisposition is assumed. Hormonal imbalances, which are regulated by the pituitary gland, are thought to play a significant role. Among other things, this gland releases two hormones: follicle-stimulating hormone (FSH) and luteinising hormone (LH). These two hormones stimulate the maturation of egg cells in the ovaries and the production of oestrogens and androgens. In PCOS, there is a particular increase in the release of LH. This stimulates the production of male hormones (androgens). Insulin resistance also appears to play an important role. Elevated insulin levels stimulate androgen production in the ovaries and reduce the formation of a protein that primarily binds testosterone. This leads to an increase in the concentration of testosterone in the blood and the onset of so-called virilisation symptoms. Being overweight, which is often linked to insulin resistance, increases this risk. However, even slim women who do not have diabetes can develop PCOS. In their case, genetic factors, stress, eating disorders and addictions are the main possible triggers.

 What are the symptoms of PCOS?

Polycystic ovary syndrome can present with many symptoms. However, all affected women have altered hormone levels in their blood and urine. Levels of LH, testosterone and other sex hormones are often abnormal. These hormonal imbalances lead to various symptoms, which do not occur in the same combination in every woman. These include:

• male-pattern body hair (hirsutism): increased hair growth on the face, between the breasts, on the inner thighs and from the pubic bone to the navel; hair loss similar to that seen in men
• a deep voice
• masculine body proportions
• enlarged mammary glands
• enlargement of the clitoris
• Menstrual irregularities: e.g. long intervals between periods, up to and including the cessation of menstruation and
• ovulation
• fertility problems
• increased sebum production
• Acne
• Overweight, ranging up to obesity
• Insulin resistance
• Multiple cysts in the ovarian region
• Metabolic changes: a typical feature is the occurrence of metabolic syndrome, a metabolic disorder characterised by excess weight, high blood lipid levels and high blood pressure

How is PCOS diagnosed?

The diagnosis is usually made by a gynaecologist. They will take a medical history and carry out a gynaecological examination. An ultrasound scan of the ovaries and the uterus is also performed, and sex hormone levels in the blood are measured. In patients who are overweight, blood sugar and blood lipid levels are checked. A diagnosis of PCOS is made if at least two of the following symptoms are present:

• numerous small cysts in at least one ovary
• very long cycles or absence of menstruation
• high levels of testosterone in the blood and/or male-pattern hair growth

It is important to note that these or similar symptoms can also occur in other conditions, which must be ruled out. These include, for example, eating disorders, hormone-producing tumours or thyroid dysfunction. Suddenly stopping the contraceptive pill should also be taken into account here.

How is PCOS treated?

Polycystic ovary syndrome cannot be cured. The aim of treatment is therefore to alleviate the symptoms. Whether or not the patient wishes to have children plays a major role in this.

Treatment for those not wishing to have children

For patients who do not wish to have children and who are also overweight and have impaired glucose metabolism, lifestyle changes are the most effective treatment. The focus is primarily on regular exercise and a balanced diet. Even moderate weight loss improves insulin resistance and reduces elevated insulin levels. This, in turn, reduces androgen production, which normalises the menstrual cycle. Sometimes doctors also prescribe diabetes medication such as metformin. This active ingredient enhances the effect of insulin, allowing blood sugar to be broken down more effectively. Furthermore, metformin can have a positive effect on the menstrual cycle, skin problems and body weight. PCOS symptoms such as skin blemishes, hair loss or excessive body hair can be counteracted with hormone therapy, for example with an anti-androgenic contraceptive pill.

Treatment for those wishing to conceive

For women with PCOS who wish to conceive, a change in lifestyle is also the first and most important step – particularly in cases of excess weight or impaired glucose metabolism. Furthermore, the ovaries can be stimulated with anti-oestrogens, which are intended to promote follicular maturation and trigger ovulation. If ovulation still does not occur, so-called gonadotropins (LH and FSH) may be administered, or pregnancy may be achieved through assisted reproduction (in vitro fertilisation). However, this carries a certain risk of multiple pregnancies. In some cases, surgery may also be advisable. During a laparoscopy, individual follicles are selectively destroyed using heat, which often normalises ovarian function and restores regular menstrual periods. Psychological issues should also be taken into account when treating PCOS. In particular, depression and anxiety disorders should be treated as part of the overall management.

Prognosis – living with PCOS

Although PCOS is a chronic, lifelong condition, with the right treatment at the right time, affected women can lead a full life and also have children.