PCOD - Polycystic Ovary Disease

PCOD - Polycystic Ovary Disease


PCOS - Polycystic Ovary Syndrome - Polycystic Ovary Disease - Symptoms - Diet- Treatment

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Polycystic Ovaries PCOD Defined PCOD Causes PCOD Prevalence PCOD Hormone Changes PCOD and Body Weight PCOD and Pelvic Pain
PCOD and Long-Term Health PCOD and Hirsutism PCOD and Amenorrhoea The Pill and Hirsutism PCOD Treatment PCOD and Metformin PCOD / Infertility Treatment
PCOD / Amenorrhoea Treatment PCOD Surgical Treatment Support Groups

What are polycystic ovaries?

Polycystic ovaries are characterised by the presence of many small cysts (fluid filled swellings) around the surface of the ovaries. The cysts are quite small ranging from 2 to 8 mm (Figure 7.1).

Polycystic ovaries are usually larger than normal ovaries and their central substance is generally more dense.

Over recent years, with the advent of ultrasound examination, we have learned that about one woman in five has polycystic ovaries. At ultrasound examination, the ovaries appear larger and more dense and the cysts look like a "necklace" around the periphery of the ovaries.

 

Figure 7.1Polycystic Ovary Picture - Note The Small Cysts Around The Periphery Of The Ovaries

Related Medical Abstracts - Click on the paper title:-

 

What is polycystic ovary disease?

When patients develop symptoms associated with their polycystic ovaries, they are said to have polycystic ovary disease ( or polyscystic ovarian syndrome).

Of the 20% of women who have PCO only one in three will have symptoms - PCOD.

In addition to abnormal menstrual cycles and infertility, some women may be troubled by skin problems, notably acne and greasy skin or unwanted hair production (hirsutism).

PCOD was first described by Stein and Leventhal in 1935 and the condition is therefore also known as Stein-Leventhal syndrome.

Many women with PCOD find it difficult to understand why they have developed symptoms, such as irregular and infrequent periods (oligomenorrhoea), after many years of normal cycles. Usually, the key factor to account for the change is an increase in weight. In association with PCOD there may be an increased level of insulin which encourages the body to lay down excessive amounts of fat tissue leading to obesity. This excess fat tissue aggravates the hormonal imbalance. A spiral may be set up as the hormone problems increase fat production and the excess fat has a further adverse effect on the hormone balance.  

Part of the difficulty in understanding polycystic ovary disease (PCOD) and interpreting the large medical literature surrounding it has been that there was no universally accepted clinical definition.(0301)

There has been a recent consensus on the diagnosis of polycystic ovary disease.(0401)

PCOD is defined as the presence of any two of the following three criteria:

  1. polycystic ovaries (either 12 or more follicles measuring 2-9 mm in diameter, or increased ovarian volume (> 10 cm3) on ultrasound.
  2. oligomenorrheoa / anovulation  (reduced periods / failure to release eggs).
  3. clinical or biochemical evidence of hyperandrogenism (excessive male hormone).

Related Medical Abstracts - Click on the paper title:-

Recommended Book:

 

 The Ultimate PCOD Handbook: Lose Weight, Boost Fertility, Clear Skin and Restore Self-esteem

PCOD Causes

Although a great deal is now known about the polycystic ovary syndrome, the exact cause has yet to be determined.

Polycystic ovary syndrome is probably an inherited condition. There has been one specific gene implicated and two others also seem to be involved. Premature balding in men is often a manifestation of the same gene that results in PCOD in women.

The hormone chemistry of polycystic ovaries is often deranged. This may result in period problems, particularly reduced or absent periods. Polycystic ovaries tend not to release their eggs regularly and, without treatment, there may be problems with fertility.

In recent years it has become recognised that many of the metabolic (body chemical) changes seen in PCOD may be related to insulin resistance.0301, 9901

Insulin is produced by the pancreas, which is a gland found in the abdomen. This gland has two functions, both related to the way the body deals with food. It secretes enzymes (chemical catalysts) into the small bowel allowing food to be broken down into the basic components that can be absorbed. The pancreas also secretes insulin into the blood stream. Insulin is a hormone  that reduces the blood sugar level, mainly by converting sugar into fat. Diabetes occurs when the pancreas can no longer produced sufficient insulin to prevent the blood sugar level rising too high. It turns out that most women with PCOD are resistant to insulin. Hormones work like a key in a lock. Insulin resistance means that the insulin hormone receptors are defective and a stronger key is required. The result is an increased output of insulin and it is the higher levels of insulin that seems to result in the typical symptoms of PCOD. Women with PCOD are not diabetic and so there is no difference in their response to a glucose (sugar) load (Figure 7.2).

Figure 7.2 Glucose Tolerance Test - Normal and PCOD women

Typically, women with PCOD require greater output of insulin from the pancreas to prevent their sugar rising too high (Figure 7.3).

Figure 7.3 Insulin Response to Glucose Load - Normal and PCOD

 

Related Medical Abstracts - Click on the paper title:-

 

It is becoming recognised that some patients have symptoms and blood chemistry (hormone levels) typical of polycystic ovary disease, although their ovaries do not have a typical PCO picture. The latest definition of PCOD allows for this.0401

Related Medical Abstracts - Click on the paper title:-

 

Polycystic Ovaries PCOD Defined PCOD Causes PCOD Prevalence PCOD Hormone Changes PCOD and Body Weight PCOD and Pelvic Pain
PCOD and Long-Term Health PCOD and Hirsutism PCOD and Amenorrhoea The Pill and Hirsutism PCOD Treatment PCOD and Metformin PCOD / Infertility Treatment
PCOD / Amenorrhoea Treatment PCOD Surgical Treatment Support Groups

 

How prevalent is polycystic ovary disease?

Polycystic ovary disease is one of the most common endocrine (hormone) disorders. Ultrasound examination provides an excellent window to look at ovarian structure. The ovaries are close to the top of the vagina and therefore transvaginal scanning shows of ovarian structure more clearly than transabdominal scanning.

In adult women, transvaginal scanning reveals an incidence of PCO in the order of 20%. About one in three with ultrasound evidence of PCO will have problems resulting in an incidence of 6-10%.

Before sexual activity has commenced ultrasound is performed by the transabdominal route. Evidence of PCO can be found in 6% of six year old girls and, by the age of ten, 18% of girls have evidence of PCO.

There is evidence that PCOD is more prevalent amongst those that are obese and in those with Type 1 diabetes or who have had gestational diabetes.

Related Medical Abstracts - Click on the paper title:-

 

For how long will I have polycystic ovary disease?

Unfortunately, PCOD is a problem that does not disappear. It is almost certainly an inherited condition. Just like the colour of your eyes, it cannot be changed.

Will polycystic ovary disease affect my general health?

There is a spectrum of severity of PCOD ranging from a little irregularity of the menstrual cycle to troublesome excess body hair and anovulatory infertility.

Early suggestions that PCOD is a cause of heart disease seems to have been unfounded. Obesity, however, is associated with heart problems and many women with PCOD are overweight. There is evidence that the long-term complications of PCOD are increased by the addition of obesity.

Young, obese women with PCOD have a high prevalence of early asymptomatic coronary atherosclerosis, compared with obese controls. This increased risk is independent of traditional cardiovascular (CV) risk factors and novel markers of inflammation. These findings underscore the need to screen and aggressively counsel and treat these women to prevent symptomatic CV disease.0701

If you have PCOD, you should make every effort to keep your weight down by diet and excercise.

Between 20 and 40% of women found to have polycystic ovary disease will develop diabetes in later life. As PCOD is associated with anovulation, the endometrium may be subjected to long-term oestrogen without cyclical progesterone protection increasing the risk of endometrial cancer (endometrial cancer).

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What hormone changes are typical of polycystic ovary disease?

Blood tests to evaluate PCOD should be scheduled early in the menstrual cycle. Some prefer the third day of the cycle and others the eighth day.

Elevated LH (menstrual cycles) concentrations, seems to be the most common finding.

The androgenic hormones (steroid hormones) testosterone and androstenedione tend to be increased and these higher levels tend to be associated with decreased SHBG levels (SHBG).

Prolactin levels (menstrual cycles, hyperprolactinaemia) are often just above the normal range. As hormone levels fluctuate there may be merit in repeating the tests.  After food insulin levels rise higher than normal (PCOD cause;  Figure 7.3). 

Related Medical Abstracts - Click on the paper title:-

Increased levels of LH can be found in 40% of women with PCO. We know that raised LH levels are associated with difficulty conceiving and increased miscarriage rates.

Related Medical Abstracts - Click on the paper title:-

What is the significance of body weight in polycystic ovary disease?

PCOD encourages weight gain and fat has an adverse effect on the hormone balance leading to an escalating spiral of the problems.

Obesity reduces the chances of pregnancy and increases the risk of pregnancy complications including miscarriage, high blood pressure and thromboembolism.

In the long-term obesity, is a major risk factor for heart disease. Every effort to maintain a normal weight by diet as well as exercise is to be encouraged. There is some evidence that women with PCOD lay down fat more easily. They may be overweight without indulging in excessive calorie intake.  

Related Medical Abstracts - Click on the paper title:-

PCOD and Pelvic Pain

PCOD is not considered to be a cause of pelvic pain

Pelvic pain and PCO are both common and not surprisingly many patients with pelvic pain also have evidence of PCO. However, PCO does not seem to be a cause for pelvic pain.

Related Medical Abstracts - Click on the paper title:-

 

Are there concerns if I have absent or infrequent periods associated with my polycystic ovary syndrome?

Infrequent periods (infrequent periods) is a common symptom of polycystic ovary disease.

If you are a sexually active woman you may be anxious that you could be pregnant.

It must be stressed that PCOD associated with infrequent or absent periods only means that the chance of pregnancy is reduced, but this can by no means be considered as a guarantee against pregnancy. Family planning (family planning) is required.

Is Polycystic Ovary Disease a cause of excess body hair - hirsutism?

PCOD is one of the more common reasons for women becoming hirsute and this sign is in fact part of the definition of polycystic ovary disease.

The biochemical changes associated with PCOD include increased levels of testosterone and reduced levels of SHBG which may result in increased male pattern hair distribution particularly on the moustache and beard areas of the face, the chest, back and lower abdomen. This may respond to medical treatment (hirsutism treatment).

Related Medical Abstracts - Click on the paper title:-

PCOD and amenorrhoea (absent periods)

If you are a sexually active woman you may be anxious that you could be pregnant. It must be stressed that PCOD associated with infrequent or absent periods only means that the chance of pregnancy is reduced, but this can by no means be considered as a guarantee against pregnancy.In the longer term, if the endometrium is being stimulated by oestrogen without the cyclical intervention of progesterone, there is a risk of the endometrium becoming hyperplastic (unduly thickened) and occasionally this could lead to malignant change (endometrial cancer). Cancer of the lining of the womb tends to be a problem around the age of fifty or sixty but can occur earlier. Twenty or thirty years ago, we would have investigated a woman with absent or infre Quent periods and if no problem was found no treatment would have been recommended. Nowadays, we recommend checking that oestrogen levels are ade Quate and offer oestrogen with cyclical progestogen if the levels are persistently low.


Related Medical Abstracts - Click on the paper title:-

 

How can the combined oral contraceptive pill treat the symptom of hirsutism associated with polycystic ovary disease?

The oestrogen in the combined oral contraceptive pill:

  • increases the oestrogen levels in the blood and this directly reduces hirsutism.
  • increases the SHBG levels and this reduces the amount of free androgen; the free androgen is largely responsible for the symptom of hirsutism.
  • suppresses gonadotrophin (FSH and LH) from the pituitary. Reducing LH production results in lower levels of ovarian androgen production.

Hormone replacement therapy involves administration of oestrogen and there is some evidence that it may have a part to play in the management of hirsutism when the pill is not acceptable.

Cyproterone acetate is an anti-androgen; it competes at the receptor sites (hormones) with androgens and reduces their effects. Dianette (Schering) is a special combined oral contraceptive pill that contains 2mg cyproterone acetate.


How can polycystic ovary disease be treated?

If you are overweight, you should make every effort to lose weight. In addition to a calorie controlled diet, regular exercise is to be encouraged. Weight reduction improves the hormone balance, the chances of pregnancy when required and also the chance of a successful pregnancy outcome.

Traditionally, treatment has depended on your presenting problems. If your main concern is infrequent periods and you do not wish to conceive, cyclical hormone treatment such as the combined oral contraceptive pill, cyclical progestogen, or hormone replacement therapy may be indicated. 

If there are associated skin problems then again the pill (perhaps with cyproterone) may be prescribed.

If you want to start a family, treatment is directed towards encouraging your ovaries to release their eggs (ova) regularly (ovulation induction PCOD infertility treatment; ovulation induction).

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How does metformin help in the treatment of PCOD

Sadly, although for a few years following the introduction of metformin for PCOD in 1998, many of us believed that it was beneficial. Recent evidence, however, has been disappointing.

The Metformin PCOD Story:In PCOD cause the recently discovered relationship between PCOD and insulin resistance has been presented. Metformin is a drug that increases sensitivity to insulin and it therefore reverses the insulin resistance of PCOD. Metformin has been used since the 1950s in the treatment of diabetes. There is accumulating evidence that metformin has a significant part to play in the treatment of PCOD, whether the symptoms are amenorrhoea (absent periods), oligomenorrhoea (infrequent periods), obesity, hirsutism (excessive hair production) or anovulation (failure to release eggs resulting in infertility). Metformin 500mg tablets are taken two or three times daily after meals. Although metformin has been available for more than forty years, its application for PCOD is new and it has yet to be licensed for this indication. We therefore provide metformin for PCOD only with informed consent (informed consent). Some women may be initially troubled by bowel disturbance and flatulence but these problems improve after a couple of weeks. The tablets can be split Infrequent periods worth taking only half a tablet daily for a few days and gradually increasing the dose over two or three weeks. At this time there is no substitute for metformin as a drug to increase insulin sensitivity but there is a new class of insulin-sensitising agents due to be launched soon the thiazolidinedionesIt will be some years before the true value of metformin for patients with PCOD will be determined. Initial experience has shown that it is beneficial for women with hirsutism and absent or infrequent periods and infertility. It may assist in weight reduction. There is theoretical reason for optimism that metformin prescribed for women with PCOD will have several long-term benefits. It was suggested that metformin may reduce complications which may occur with ovulation stimulation particularly with gonadotrophin injections:

A thirty-five year old woman had stopped seeing her periods (amenorrhoea) for a year and her weight had been increasing. Her only other problem was IBS (Q23.34). Her BMI was 38 (Q9.8) showing that her weight was 50% greater than it should have been. Ultrasound examination of her pelvis showed no abnormality and in particular there was no suggestion of polycystic ovaries. Her LH was 8.4 IU/l and FSH 4.8 IU/l which are normal readings and her thyroid tests and prolactin were normal. The testosterone was 3.2 nmol/l which is towards the upper level of normal but her SHBG was low at 14 nmol/l. Her fasting blood sugar was 4.8 mmol/l (normal) but her fasting insulin was 18.7 mU/L which is high. Metformin was commenced.

This case is an example of a patient presenting with two problems that can be associated with polycystic ovary disease namely amenorrhoea and obesity although the ultrasound was reported as showing normal ovaries. Her LH was not high and even her testosterone was just within the normal range. The low SHBG is a strong pointer to the diagnosis. Although the high fasting insulin in this case seems reassuring that metformin is likely to prove beneficial the value of insulin tests in clinical management remains to be determined.

Related Medical Abstracts - Click on the paper title:-

PCOD and metformin

Please see above- The recently discovered relationship between polycystic ovary disease and insulin resistance has been presented above. Metformin is a drug that increases sensitivity to insulin and it therefore reverses the insulin resistance of PCOD. Metformin has been used since the 1950s in the treatment of diabetes and it is a remarkably safe drug.

There is accumulating evidence that metformin has a significant part to play in the treatment of PCOD, whether the symptoms are amenorrhoea (absent periods), oligomenorrhoea (infrequent periods), obesity, hirsutism (excessive hair production) or anovulation (failure to release eggs resulting in infertility). Metformin 500mg tablets are taken two or three times daily after meals. Although metformin has been available for more than forty years, its application for PCOD is new and it has yet to be licensed for this indication. We therefore provide metformin for PCOD only with informed consent (informed consent). Some women may be initially troubled by bowel disturbance and flatulence but these problems improve after a couple of weeks. The tablets can be split Infrequent periods worth taking only half a tablet daily for a few days and gradually increasing the dose over two or three weeks. At this time there is no substitute for metformin as a drug to increase insulin sensitivity but there is a new class of insulin-sensitising agents due to be launched soon the thiazolidine will be some years before the true value of metformin for patients with PCOD will be determined. Initial experience has shown that it is beneficial for women with hirsutism and absent or infrequent periods and infertility. It may assist in weight reduction. There is theoretical reason for optimism that metformin prescribed for women with PCOD will have several long-term benefits. It has been suggested that metformin may reduce complications which may occur with ovulation stimulation particularly with gonadotrophin injections:

Metformin has been used for many years by diabetic patients and there is no evidence that it causes such problems in pregnancy. Once pregnancy has been confirmed, there is no proven advantage in continuing treatment but there is some early eInfrequent periodsinue the metformin until 20 weeks into the pregnancy and others continue the metformin throughout the pregnancy.

Related Medical Abstracts - Click on the paper title:-

 

How should infertility associated with polycystic ovary disease be treated?

PCOD is associated with ovulation problems (egg release) and therefore ovulation induction is often required. The ovaries will often respond to tablets; Tamoxifen (tamoxifen infertility) is thought to provide a good balance of hormone production although clomiphene (Clomid clomiphene citrate) may also prove to be effective.

Metformin has been shown to be effective in the treatment of polycystic ovary disease. For several years, many infertility specialists increasingly turned to metformin as first-line treatment for infertility associated with polycystic ovary disease. However, there is now evidence that clomiphene should be the first-line treatment and metformin added if pregnancy is not achieved.

If the ovaries do not respond to tablets more powerful agents (gonadotrophins e.g. Pergonal, Humegon or Metrodin gonadotrophins) given by injection will almost invariably prove to be successful. Increased levels of LH occur in 40% of women with PCOD and this seems to reduce the chance of conception and there is also an increased risk of miscarriage. LH levels can be suppressed by GnRH agonists (gonadotrophins) but disappointingly studies in these situations have shown no improvement.

Ovarian drilling (ovarian drilling) may have a part to play when ovulation stimulation proves difficult to achieve with drugs. Before commencing ovulation stimulation, it seems sensible to ensure reasonable male fertility by checking a semen analysis. Many authorities recommend testing Fallopian tube patency before commencing treatment. My own view is that if there is clear evidence of PCOD and anovulation, a few months of treatment before confirming tubal patency will save many women from an uncomfortable procedure.

Related Medical Abstracts - Click on the paper title:-

 

Treatment of Absent periods associated with PCOD

The combined oral contraceptive pill is often the most appropriate method for providing cycle control, assuming that conception is to be avoided. If oestrogen levels are satisfactory, regular withdrawal bleeds are likely to follow cyclical progestogen administration (Q5.12; Q 24.17). When the patient is a young teenager, parents often feel happy with this rather than knowing that their daughter has started a contraceptive agent. Another option is the use of a cyclical HRT (Q 28. 9). Metformin should also be considered.

Related Medical Abstracts - Click on the paper title:-

You can never rely on irregular periods as a symptom of anovulation (eggs not being released). The best advice is that you should not take unnecessary chances.

Related Medical Abstracts - Click on the paper title:-

Can PCOD be treated surgically?

The doctors who first described PCOD removed part of the ovaries (wedge resection), for microscopic examination. They observed that the menstrual cycle and fertility were often restored following these operations.

More recently, it has been shown that drilling tiny holes in the ovaries (ovarian drilling) at the time of laparoscopy, may improve their chemistry although it is too early to know how long this improvement will be sustained. Whilst ovarian drilling may have a part to play in PCOD patients with infertility, this treatment is not proven to have a definite place in treatment for hirsutism.

Ovarian drilling may result in spontaneous ovulation. Unlike ovulation stimulation, there is no increased risk of multiple pregnancy or ovarian hyperstimulation (enlargement of the ovaries with the possibility of other problems such as excess fluid in the abdominal cavity). We do not know why ovarian drilling works. For those patients who respond to ovarian drilling there appears to be a reduction in LH levels which suggests that the drilling must in some way alter the hormone feedback to the hypothalamus and pituitary possibly by the release of a factor not yet identified. Interestingly, in one study where four patients had drilling of just one ovary, there was evidence of ovulation from the other ovary in the first cycle after treatment in three of the patients.

One study has shown that the insulin response to sugar is not altered following ovarian drilling.

Related Medical Abstracts - Click on the paper title:-

Support Groups

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others' experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

  PCO Association P.O. Box 7007 Rosemont IL 60018 USA

 

http://www.verity-pcos.org.uk Verity and PCO

 

 52-54 Featherstone Street London EC1Y 8RT.
http://www. Pcosupport.org//    
http://www. Mja.com. Au    
pcos friendly.co.uk/    
health.groups    
pcos. Tripod    
cedars-sinai    
http://pcos. Meetup.com    
www.soulcysters.net/    
ww.uhcw.nhs.uk/ivf/supportgroups    
pcos-vitaline    
pcos world wide support  

 

Polycystic Ovaries PCOD Defined PCOD Causes PCOD Prevalence PCOD Hormone Changes PCOD and Body Weight PCOD and Pelvic Pain
PCOD and Long-Term Health PCOD and Hirsutism PCOD and Amenorrhoea The Pill and Hirsutism PCOD Treatment PCOD and Metformin PCOD / Infertility Treatment
PCOD / Amenorrhoea Treatment PCOD Surgical Treatment Support Groups

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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London.

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PCOD - Polycystic Ovary Disease