In 1935 Drs. Stein and Levinthal described a syndrome in which women suffered irregular, usually rare, periods, hirsutism (hair growth), and experienced varying degrees of infertility. Today we call it Polycystic Ovarian Syndrome (PCOS).
It’s most general definition is a syndrome in which there is too much male-type (androgen) hormone produced by the ovaries (and sometimes the adrenal glands) with associated disruption of the normal hormonal cycle. It’s exact cause is unknown, but it seems to be hereditary. Almost one of twenty women of reproductive age have it, and it is one of the most common causes of infertility.
The most simplistic thinking about it in the past was the concept of ovulation failure: certain areas of the ovarian capsule, for some reason, had trouble releasing an egg; with this, the rest of the cycle got hung up with precursor hormones, like testosterone, building up. Ovarian wedge resection, a surgical procedure in which a portion of the ovarian capsule was cut out, was the standard treatment until the invention of birth control pills which overrode the entire hormonal cycle and with it, any abnormalities. Today, the entire cycle is overridden with birth control pills until a woman is ready for pregnancy. At that point, ovulation induction is carried out. Wedge resection is an outdated surgical treatment. Although it will more than likely improve ovulation, it won’t do anything to help the effects of androgen excess.
Today treatment is based on whether pregnancy is sought or not: if so, induce ovulation with drugs like Clomid; if not, suppress the entire cycle artificially with birth control pills.
But the plot thickens…
Recent advances in understanding this disorder have demonstrated other problems besides alterations in the menstrual cycle and ovulation. For one thing, there’s a certain tendency toward diabetes with a phenomenon called “insulin resistance.” It’s not that there’s too little insulin, but that the insulin made is not as good. Therefore, handling sugar is impaired. The body responds by making even more insulin, and the extra insulin tends to stimulate other tissues that normally aren’t particularly responsive to insulin. One of the tissues is the ovary, which is stimulated to make extra androgen (testosterone). Other effects on other tissues include:
stimulation of the lining of blood vessels, causing hypertension;
effects on the liver and on cholesterol metabolism, contributing further to heart disease;
and a decrease in sex hormone-binding globulin (SHBG), which means less sex hormone is bound (“tied up”) and therefore free to act.
The “bound up” testosterone is fairly unreactive. The free testosterone is what has the classical male hormone-like effects, like hair growth, acne, and disruption of the normal ovulation and cycling. There accumulates a collection of early follicles that don’t go any further. (An ovary in such a state is, however, “loaded” such that there is an exaggerated response to induction of ovulation with a greater risk of twins and triplets from multiple simultaneous ovulations.)
The “full-blown typical” PCOS patient has a history of only occasional ovulations (<8 per year) and prolonged cycles of greater than 35 days, male-like hair distribution or hair loss, obesity, multiple ovarian cysts, acne, and laboratory assessment demonstrating too much testosterone. But there are varying degrees of PCOS, and many women with it have only few or isolated aspects of the disorder. And diagnostically, that can be a real problem! Although insulin resistance is independent of weight, still being overweight can make it worse. Most patients with PCOS are advised to lose weight. Other things besides PCOS can cause an increase in testosterone. Since this hormone is also produced in the adrenal gland, disorders (including cancer) of the adrenal need to be considered and/or ruled out. Care of a patient with PCOS includes testing for diabetes (fasting blood sugar, HbA1c), abnormal lipids (cholesterol, triglycerides, etc.), and measuring the amount of insulin resistance (with a glucose-to-insulin ratio). Treatment goals are: Reduce hair-growth problems and acne; Manipulating the cycles hormonally to re-establish regular menstrual periods. (Too long stuck in the first part of the cycle can lead to overstimulation of the uterus by estrogen, possibly leading to uterine cancer.) Re-establishing fertility by re-establishing ovulation (if pregnancy is desired). The Fork in the Road If a woman with PCOS isn't seeking pregnancy, birth control pills will effectively create artificial cycles that will prevent irregular bleeding, prevent a tendency to uterine cancer, and decrease the amount of testosterone produced by the ovaries. If a woman seeks pregnancy, then ovulation inducers like Clomid can be used. Some infertility doctors also give insulin-sensitizing agents (which can "resensitize" the insulin, another way to describe a lowering of insulin-resistance). Spironolactone, which is actually a diuretic ("fluid pill"), competes with testosterone at the sites where testosterone acts on tissue. But this drug may mess up potassium and have other side effects, like other diuretics. PCOS is not quite the disorder Drs. Stein and Levinthal thought it was. There seems to be a lot more to it than that. But they were a crucial beginning in helping women when they recognized the link between certain symptoms and an abnormal medical condition unique to women. The importance of this beginning is only now being appreciated inasmuch as we're beginning to see PCOS as it relates to heart disease, infertility, and diabetes. We may be seeing the light at the end of the tunnel, but Drs. Stein and Levinthal found the right spot and dug that tunnel. ©2000 Gerard M. DiLeo, M.D. source: http://www.gynob.com/pcos.htm