Polycystic Ovarian Syndrome: A Review Written for Patients

How common is polycystic ovarian syndrome?

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine diseases affecting about six percent of reproductive age women. PCOS is one of the main reasons women have difficulty conceiving. About half of all women who do not ovulate on a regular basis will be diagnosed with PCOS.

In recognition of PCOS Awareness Month, I've developed this review for patients dealing with this disease.

How is PCOS diagnosed?

As a syndrome, PCOS is a constellation of findings. Alone, it really is not a disease but simply a label. But physicians use these labels to our patients’ advantage. If we suspect PCOS, we will search for the problems that commonly accompany PCOS, minimizing their effect while possibly changing the course of the illness.

PCOS requires at least two of these three problems for a diagnosis:

  1. Ovulatory dysfunction: irregular cycles or blood progesterone levels that indicate failed ovulation.
  2. Ovarian hyperandroginism: excess male hormones including an unusual amount of facial/body hair or elevated male hormones, such as testosterone, in blood tests.
  3. Polycystic ovaries on transvaginal ultrasound: more than 12 small 3-9mm follicles within each ovary as seen on an ultrasound. At times, we will see the signs of a classic “necklace,” with small cystic follicles located on the periphery of the ovary and which look like a pearl necklace.

Clinically, there seem to be two main types of PCOS: 1) Patients who were essentially born with the problem and have never really had normal cycles, and 2) Patients who have had normal cycles but demonstrate symptoms as they gain weight. Upwards of 80% of all PCOS women are heavy, but 20% can be quite slender.

Other issues include thyroid problems, elevations of the pituitary hormone prolactin and a handful of rare inheritable enzyme deficiencies. These problems need to be screened for and ruled out before settling on the diagnosis of PCOS.

PCOS is probably the single most common diagnosis we see in our patients. Its incidence has been increasing over the last 20 years as the US population has shifted from normal weight to the overweight, obese and morbidly obese categories.

How do you diagnose pre-diabetes in the PCOS patient?

To diagnose insulin and glucose problems, commonly called pre-diabetes, we prefer a 10-12 hour fast with baseline glucose and insulin levels rather than fasting glucose levels alone. The endocrine system is then challenged by having the patient drink 75 grams of glucose (Glucola®), which is called a Glucose Tolerance Test (GTT). Two hours later, insulin and glucose levels are repeated to complete the study. We do not require blood tests every 30 minutes as some protocols suggest, since the fasting and two-hour results are sufficient.

Insulin resistance or actual diabetes is present in nearly half of all PCOS patients. The more the patient weighs, the more likely the diagnosis.

What really causes PCOS?

While many women believe their hormone imbalance is mainly caused by testosterone, insulin seems to be the key hormonal culprit. Excess insulin stimulates the ovaries to produce excess male hormones. Also, excess insulin predisposes the PCOS patient to numerous medial problems, including cholesterol elevation, hypertension and possibly heart disease. Insulin is the key.

How is PCOS best treated?

Treatment in the overweight PCOS patient includes diet, exercise, weight loss and aggressive prevention and treatment of pre-diabetes (insulin resistance and/or glucose intolerance).

Beyond this basic treatment, there are generally two treatment pathways: the “quality of life path” and the “pregnancy path”.

Quality of Life Path

PCOS patients who are not trying to get pregnant should follow the quality of life path and focus on treating the signs and symptoms. Because they don’t shed the inner endometrial lining on a regular basis, PCOS patients are at greater risk for abnormal uterine bleeding, anemia, endometrial polyps, pre-cancer and eventually, even cancer of the lining of the uterus. Hormonal control is used in this pathway. We also suggest aggressive treatment for hair growth, including the use of hormones, electrolysis or laser hair removal. The psychological affects of excess facial and body hair on women should not be minimized and may be the primary concern for PCOS patients.

Pregnancy Path

We recommend that PCOS patients who want to get pregnant use a winning combination of diet, exercise, weight loss and anti-diabetic medications such as metformin (Glucophage®) that are combined with ovulatory medications. Metformin helps in a number of ways including dropping male hormone levels in half and assisting in weight loss. Gas and diarrhea results when too many carbohydrates are consumed while taking metformin, so patients must learn to eat better to avoid the symptoms.

Our practice commonly uses letrazole (Femara®) to stimulate ovulation but sometimes we need to prescribe the old tried and true clomiphene citrate (Clomid®). We occasionally have to suppress the adrenal male hormones through the addition of dexamethasone. We need to be very careful about prescribing injectable follicle stimulating hormone (FSH) medications for PCOS patients since they tend to open the floodgates, resulting in a release of multiple eggs and the potential for a multiple pregnancy. Overstimulation of the ovaries can also lead to significant illness.

Miscarriages seem to occur more often in the PCOS patient. It may have to do with their weight and abnormal insulin levels. While somewhat controversial, even PCOS patients without obvious glucose/insulin problems may benefit from metformin treatment. It must be understood that while these drugs have been extensively studied in the treatment of diabetes, insulin resistance, glucose intolerance and PCOS, the FDA has not granted official approval for the use of these drugs for PCOS.

PCOS patients also more commonly experience gestational diabetes during pregnancy. Weight gain during pregnancy should be held in check as excessive amounts of weight gained can result in insulin dependent diabetes during pregnancy and even afterwards. Pregnancy complications are more common in patients with gestational and insulin dependent diabetes, so an obstetrician will need to carefully monitor a PCOS patient during her pregnancy.

What are long-term concerns for the PCOS patient?

Women with PCOS are at significant risk of developing insulin and non-insulin dependent diabetes mellitus, uterine cancer, elevated lipids, hypertension and cardiovascular disease.

Will a PCOS diagnosis and treatment be covered by insurance?

The coverage of PCOS will depend upon the insurance company. Your physician will try to emphasize the medical diagnoses that are seen with PCOS, such as an ovulatory dysfunction, hirsutism, glucose intolerance or insulin resistance, but coverage cannot be guaranteed. The diagnosis of infertility for the PCOS patient is less often covered but it entirely depends on the particular insurance plan. Medications such as metformin are commonly available free at some pharmacies and supermarkets, so co-pays aren’t even necessary to obtain the medication.

Can PCOS be cured?

In patients that have always had menstrual issues, even when young and slender, an actual cure has not yet been found. However, in the population who became symptomatic after weight gain, diet, exercise, weight loss and medications may actually result in a cure. This “cure” continues as long as the patient’s weight remains close to the level when ovulation and regular cycles returned.

PCOS is a metabolic disease and will require careful control for most patients throughout their lives. That doesn’t mean that the PCOS patient can’t have a family or will always have to suffer the symptoms. Through dedication by the PCOS patient with the assistance of your obstetrician/gynecologist or your friendly neighborhood reproductive endocrinologist, the signs and symptoms of PCOS can certainly be controlled and minimized.

Craig R. Sweet, M.D.
Medical & Practice Director
Reproductive Endocrinologist
Specialists In Reproductive Medicine & Surgery, P.A.

Documents of Interest to the PCOS Patient:

ASRM PATIENT FACT SHEET, Ovarian Drilling for Infertility

ASRM, Hirsutism and Polycystic Ovarian Syndrome, Patient Information Series

ASRM, Patient Fact Sheets, Polycystic Ovarian Syndrome

ASRM, Patient Fact Sheet. Ovarian Drilling for Infertility

PCOS Links of Interest:

The PCOS Challenge:



Why This Florida Infertility Doctor is Concerned About Mississippi Initiative 26

Today, the good people of Mississippi will go to the polls to exercise their constitutional right to vote. One of the items they will cast their ballot on is Mississippi Ballot Initiative #26, which would give “personhood” to a fertilized egg. If enacted, this law will cause a chilling effect that will be felt throughout the infertility field as other states like Florida and Ohio, to name just two, gear up for similar referenda in 2012. The passage of Mississippi Initiative 26 will signal the start of a dangerous precedent, that if it gains momentum, will cause dire consequences for many of my patients.

This isn’t just about abortion, although this is what the proponents would like you to believe. Let me be clear, I don’t think the intention of the well-meaning individuals who may vote for this Initiative want to do harm. In fact, I am certain, people voting for the initiative probably feel they are saving lives. The problem is that Initiative 26’s proponents have not given the voters the right facts about the law’s devastating consequences in the state of Mississippi. The list of unintended consequences extends far and wide and involves women’s healthcare, the legal world and the infertile patient as well as the providers of their medical care.

Consequences to Women’s Healthcare

The following are very likely consequences of the passage of the amendment:

  • – The total outlawing of abortion, even in the cases of incest and rape.
  • – Outlawing of the vast majority of contraceptives including the IUD, the “morning-after pill” and Depo-Provera. Even hormonal contraceptives including oral contraceptives, patches and rings will thin the uterine lining preventing implantation. If interpreted as such, they will be outlawed. The only contraception that will probably remain will be condoms and we know how much men like to take a shower with a raincoat on….
  • – How can a physician surgically remove a tubal ectopic pregnancy thus terminating the life of an “embryo-person”? No, really, could someone tell me how a physician will be able to care for a patient with a life-threatening ectopic pregnancy?
  • – Are we really going back to the “good old days” when women were dying on a regular basis from botched backstreet abortions? Who will take care of the orphans?

Consequences to the Legal World

There are literally thousands of instances where the word “person” is written in the Mississippi statutes, each of which will have to be carefully reviewed to see how three-day old eight-cell stage embryos fit in. Think of the possible consequences:

  • – How will cryopreserved embryos inherit? Exactly what rights will they have?
  • – If embryos are created in Mississippi by a couple visiting from another state or another country, are they instantly going to be US citizens or citizens of the state of Mississippi?
  • – Will all embryos that do not survive have to undergo a burial? If they die unexpectedly, are they to undergo an autopsy?
  • – Women who smoke, drink in excess or use recreational drugs are at an increased risk for miscarriages. Are they to be charged with manslaughter or perhaps even murder if they are aware that their behavior could end the life of an “embryo-person”?

Disastrous Consequences to the Infertility Patient and Provider

It is clear that the proponents of initiative 26 feel the infertile patients are expendable. They don’t care that women and men’s lives and the families of Mississippi will be severely affected:

  • – Embryologists might be charged with manslaughter if embryos fail to survive in the laboratory.
  • – Will the laboratory even try to thaw frozen embryos understanding that at least 10-20% of them will not survive the thaw? Will the less expensive frozen embryo transfer procedures just disappear?
  • – If the physician transfers the embryos but the patient doesn’t conceive, will the physician be blamed? Will the doctor be accused of manslaughter for the failed implantation?
  • – Will frozen embryos be able to be moved outside of or into the state of Mississippi? Will Fedx take the chance of being accused of manslaughter should a transport tank fail in transit?

What will probably happen is that IVF will continue but physicians will only remove 2-3 eggs in a cycle. This will greatly increase the cost of the infertility treatment and result in much lower success rates. Those that can afford will go elsewhere. Who cares? For one, I do and I will bet every one of my patients will if Initiative 26 passes in Mississippi and they move on to other states, including Florida.

Well-Meaning Intentions With Unintended Consequences

This initiative is a really bad idea and has far more unintended consequences that I can even outline here in this short blog. The abortion decision is a personal decision between a woman, her partner, her conscience, her religion and her creator. We’ve been through this for years and years and the majority of Americans agree with this statement.

If Mississippians pass this law today, I know my work fighting the consequences of the Personhood Movement has just begun. Florida most likely will be one of the next states in their crosshairs. I will be forced to spend time, money and effort fighting these initiatives that I could otherwise devote to building families by encouraging the donation of unused embryos to patients in need. Instead of helping bring children into this world, I will be working diligently so I can prevent similar misguided political acts from destroying my patients’ dreams. Let’s hope the voters of Mississippi don’t find out too late that their actions have stymied the very goal they were trying to achieve – building loving families that would otherwise not exist.

Vote “No” on Initiative 26.

Craig R. Sweet, M.D.
Medical & Practice Director
Reproductive Endocrinologist
Specialists In Reproductive Medicine & Surgery, P.A.