The Enigma of Polycystic Ovary Disease
by William H.E. Romero, MD,

The February 2004 issue of Readers' Digest identified Polycystic Ovary Syndrome (PCOS) as one of the 10 medical conditions most commonly missed by physicians. This is unfortunate because PCOS is an extremely common endocrine condition in women. It estimated that one in 10 to 20 (about 5 to 10 million) American women between the ages of 15 to 35 are affected by PCOS. PCOS has very serious physical, psychological and metabolic consequences. It could lead to the development of depression, diabetes, hypertension, heart conditions and uterine cancer.

Presentation. PCOS typically develops during adolescence. The most common findings are infertility (74%), irregular menstrual cycle (70%), excessive facial hair or acne (69%) and obesity (41%). Up to half of women attending fertility clinics have PCOS. On average, affected women have 6-8 periods a year with 35 days in between. The weight gain is concentrated around the waistline. Other findings include anxiety and depression, a dark, thickened dark skin on the back of the neck and skin tags around the neck.

There is an intense hunt for the cause of PCOS. Presently, all we have are theories that point to insulin resistance as the root cause. Normally, insulin facilitates the entry of blood sugar into our body cells, which then converts the sugar into energy. Insulin resistance exists when the cells do not respond to insulin. The pancreas reacts by secreting more insulin. The elevated level of insulin starts the cascade that leads to PCOS. The maturation of ovarian follicles into eggs is impaired. These follicles are trapped in the ovaries and form cysts, thus, the name "polycystic ovaries". Also, the balance of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) is disrupted causing an irregular menstrual cycle. The lack of viable eggs and imbalance of hormones contribute to infertility. Another effect of high insulin levels is the increase in the male hormone, testosterone. This leads to thick facial and body hair, acne and thinning of scalp hair. Insulin also increases the deposition of fat.

The diagnosis is mainly clinical. The astute physician looks for clues like irregular and painful menstruations, signs of elevated testosterone (excess facial and body hair and severe acne), and in young women, for a history of infertility or subfertility. It is easy to miss the signs of PCOS. For one, menstrual irregularity and rapid weight gain are notoriously common in teenage girls. To add to the confusion, girls start shaving facial and leg hair and using birth control pills at an early age. Infertility could be masked by modern fertility techniques. The unsuspecting physician may therefore overlook the cardinal signs of PCOS: subfertility, menstrual irregularity and hirsutism. Blood tests can confirm a suspicion of PCOS. It could show high levels of testosterone, a reversal of the FSH to LH ratio, and a low range of Sex Hormone Binding Globulin (SHBG). An ultrasound of the ovaries may show a confluence of cysts around the edges, resembling a pearl necklace. PCOS is more common in families with a history of diabetes and PCOS.

Until we know what causes PCOS, it will be difficult to find a cure. There is no FDA-approved treatment either. Presently, physicians are using metformin, which is intended for diabetics. Metformin helps the cells be more sensitive to insulin and facilitates the entry of blood sugar. It results in lowering the level of circulating insulin and has an overall effect of reversing PCOS.

Certain birth control pills are better than others in regulating menstruation and in reversing the effects of testosterone. A few medications, like spironolactgone, could reverse the effects of testosterone. Some medications found useful in Europe are not available in the U.S. Diet and exercise are extremely important. Insulin resistance slows down the processing of blood sugar. Excess blood sugar is stored as body fat around the waist resulting in an apple-shaped body. The quantity and quality of carbohydrates consumed is critical. The amount of carbohydrate intake should be limited to about 40% of the total daily intake. Low glycemic carbohydrates, which slowly convert to sugar, are preferable.

Exercise promotes the conversion of blood sugar into energy. The less available sugar, the less insulin is secreted. Exercise therefore reduces the level of circulation insulin. Obesity contributes to insulin resistance, resulting in a vicious cycle. Weight loss is slow in PCOS but is crucial.

Early recognition of PCOS is necessary to give young women with PCOS the chance to get pregnant. Early diagnosis is important for the development of a young girl's self-esteem. How can a girl with acne, facial hair or obesity face the world? Parents should be familiar with and look out for PCOS. Just remember that not all affected females will exhibit every sign of PCOS. If you know of a teenager with irregular menstruation, obesity, acne and thick facial and body hair, or a young woman with difficulty getting pregnant, suggest that she be tested for PCOS, especially if there is PCOS or diabetes in her family.

Dr. Romero lectures nationally on PCOS. He is a board-certified obesity and nutrition specialist. He specializes in cases of resistant obesity resulting from PCOS, hypothyroidism, nocturnal eating and reactive hypoglycemia. He practices in Huntington (631-549-4500) and Garden City (516-222-1456).