Do you know what the most common cause of female infertility is? Polycystic ovary syndrome, also known as PCOS. It is estimated that 15-20% of women will be diagnosed with PCOS at some point in their lives.1 It is the most common endocrine (hormone) disorder for women of reproductive age.2 Approximately 90-95% of women with anovulation (not ovulating) who attend infertility clinics have PCOS.1 It is a major concern for women. So, what do we know about PCOS and what is the latest research on it?
PCOS was first reported in 1935, but the criteria to diagnose it were not derived until much later. PCOS is diagnosed by exclusion, because many other impairments, such as thyroid dysfunction, can have the same symptoms. There is no single diagnostic test for PCOS, but most experts agree to use the Rotterdam Criteria of 2003 to diagnose PCOS, which are that two of the following three symptoms must be present in order for PCOS to be diagnosed: clinical and/or biochemical hyperandrogenism, polycystic ovaries, and/or chronic anovulation.2 Insulin resistance and hyperinsulinemia are common with women with PCOS, however testing insulin levels is not required for a diagnosis of PCOS.1
Three main symptoms:
Hyperandrogenism is an excess of male hormones, such as testosterone, in the female body. It can be clinical, biochemical, or both.3 Clinical hyperandrogenism presents as acne, hair loss, and/or hirsutism (unwanted male-pattern hair growth). Biochemical hyperandrogenism is an increase in androgens (male sex hormones) in the female body and is assessed through hormone laboratory tests.
In anovulation, the oocyte or egg is not released. This can lead to an unpredictable menstrual cycle. Menses that occurs at less than 21 days or greater than 35 days are indicative of ovulatory dysfunction.3 It’s important to know that anovulation can occur with regular cycles as well.
A polycystic ovary is one that has multiple cysts. Follicles in the ovary are stimulated by hormones to release an egg. However, if the egg is not released, the follicle can continue to grow, and turn into a cyst. Experts agree that a diagnosis of a polycystic ovary is defined as having 12 or more antral follicles that are 2-9 mm in diameter and/or the ovarian volume is greater than 10 mL.3 Not every women with PCOS has polycystic ovaries, which is why screening for hyperandrogenism is important.
PCOS is responsible for a number of symptoms and it adversely affects the endocrine, metabolic, and cardiovascular systems.1 Please check out PCOS Awareness Association for more information on symptoms. For a list of health risks associated with PCOS, please visit UCM’s link.
What’s the latest research on PCOS?
Genetic, metabolic, endocrine, and environmental abnormalities all contribute towards PCOS, making it a multifactorial disorder. However, the latest research suggests PCOS may be caused by an elevated anti-Mullerian hormone (AMH).4 In May 2018, the medical journal Nature Medicine published an article by Tata et al. with new evidence that demonstrates an increase of AMH in utero may affect the development of the female fetus contributing towards their development of symptoms of PCOS later in life. Women with PCOS have higher AMH levels: according to Tata it can be two to three times higher than women without PCOS. It used to be thought that AMH typically decreases during pregnancy, but Tata et al’s research found that women with PCOS continue to have elevated levels of AMH, particularly if they are lean. (For some reason, obese women with PCOS do not have the same elevated AMH levels as lean women during pregnancy. More research is needed to fully understand the difference between the two body types.) With this new discovery, Tata and her team wanted to know if an elevated AMH level could cause PCOS. To do this, they injected higher levels of AMH into pregnant mice and followed the neuroendocrine characteristics of the babies. They found that the female mice babies developed PCOS-like reproductive and neuroendocrine characteristics in adulthood. This is an extremely important finding. In the past, researchers thought PCOS was passed genetically, however they were never able to find the exact gene that caused PCOS. It turns out, a hormone is the culprit.
Tata and her team took the research one step further and found a new way of treating PCOS in mice. They administered the drug cetrorelix, which is a GnRH antagonist drug used in IVF treatment, to the babies and found their neuroendocrine abnormalities were normalized. Does this mean the mice were cured of PCOS? I’m not sure, but it does open the door for new treatment that can potentially restore ovulation and pregnancy for women. The researchers are planning a clinical trial of cetrorelix to women with PCOS soon.5 We’ll need to keep an eye out for their findings.
For now, treatment of PCOS is focused on alleviating symptoms. Here’s a checklist that your doctor might go through.
- Treatment for androgen related symptoms:
- Oral contraceptive pill (OCP) is the first line of treatment
- Hair removal for hirsutism: laser hair removal, waxing, or prescription creams
- Antiandrogen medication, such as spironolactone, if OCP and hair removal don’t work
- There is limited data on appropriate treatment for alopecia
- Treatment for hyperinsulinemia:
- Metformin, which lowers insulin by improving insulin sensitivity and in return can decrease circulating androgen levels
- Treatment for anovulation:
- OCP, such as a cyclic progestin or a low dose combined hormonal contraceptive that contains estrogen and progestin, to help with inhibiting endometrial proliferation – this is the primary recommended treatment
- Weight loss: 5-10% reduction in weight can improve androgen levels and improve menstrual function and possibly fertility.1
- Treatment for infertility:
- Weight loss is the first-line of treatment
- Clomid is the first drug of choice
- Works by causing the release of GnRH by the hypothalamus leading to an increased release of FSH from the pituitary gland
- IVF (In vitro fertilization)
- For more information on fertility, please visit Rachel’s blog
Finally, how can pelvic floor physical therapy help?
Pelvic floor physical therapy can help with the pain that can be associated with PCOS, which can include abdominal pain, pelvic pain, pain with sex, and dysmenorrhea (painful periods). Not every woman with PCOS experiences pain, but some do, and PT can help. Visceral manipulation, which is a manual therapy technique used to help restore normal movement and function of the organs, may help with fertility. Research is limited on visceral manipulation and PCOS; however, if you have had a good experience with it, please leave a comment in the comment section below. To find out what a good pelvic floor PT treatment session is like, please read Stephanie’s blog.
PCOS is a major concern for women; however, treatment is available for the associated symptoms, and the latest research brings hope for a cure.
- Surmins S and Pate K. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical Epidemiology. 2014. V.6.
- Goodman N, et al. American association of clinical endocrinologists, american college of endocrinology, and androgen excess and PCOS society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome – part 1. Endocrine Practice. Nov. 2015. Vol 21 No.11.
- McCartney C. and Marshall J. Polycystic ovary syndrome. N. Engl J Med. July 2016. 375(1): 54-64.
- Tata B, et al. Elevated prenatal anti-Mullerian hormone reprograms the fetus and induces polycystic ovary syndrome in adulthood. Nature Medicine. June 2018. Vol 24, 834-846.
- Klein, A. Cause of polycystic ovary syndrome discovered at last. NewScientist. May 14, 2018. https://www.newscientist.com/article/2168705-cause-of-polycystic-ovary-syndrome-discovered-at-last/