Polycystic Ovarian Syndrome

Synonyms

Polycystic ovary syndrome, PCOS
Stein-Leventhal syndrome

definition

Polycystic Ovarian Syndrome is a complex of symptoms consisting of a lack of menstrual bleeding (amenorrhea) or prolonged menstrual breaks (oligomenorrhea), increased body hair (hirsutism) and overweight (obesity) and is due to hormonal dysfunctions of the ovaries (ovaries) in women. The symptom complex was described by Stein-Leventhal in 1935.

Epidemiology / incidence in the population

The Polycystic Ovarian Syndrome is increasingly found in women between the ages of 20 and 30.
However, the actual onset of the disease is already suspected in puberty and is either diagnosed during routine examinations or only when the disease becomes symptomatic.
Approx. 5% of women of childbearing potential have polycystic ovarian syndrome.

causes

The root cause polycystic ovarian syndrome, which manifests itself on the one hand through various symptoms, but also in the Ultrasonic in the form of many distributed in the ovary Cysts can be seen is largely unknown.
It is assumed that the hormones work together incorrectly FSH and LH but the cause is not yet known. In the so-called Hypothalamus in the brain, which is responsible for the production of many hormonal precursors, becomes the so-called Gonatotropin releasing hormone (GnRH) poured out. This then acts on the pituitary glands (pituitary glands) in the brain and causes the two hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to be released, both of which affect the Ovaries (ovaries) and act on the menstrual cycle.
GnRH is released from the hypothalamus in a specific time pattern. FSH and LH are then stimulated. At some point, both hormones drop briefly, which initiates ovulation. Shortly afterwards, the two hormones rise again. In women, FSH affects both Menstrual cycle, as well as the formation of the gonads. The release of FSH promotes granulosa cell growth in the Ovaries. Luteinizing hormone (LH) triggers follicle maturation and, ultimately, ovulation. It also causes the development of the so-called corpus luteum, which is responsible for the hormones estrogen and produces progesterone.

At the Stein-Leventhal syndrome there is probably a lack of activity of certain enzymes (aromatases) in the above-mentioned granulosa layer in the ovary. In healthy women, this layer is stimulated by FSH.
In the sick patient, a hyaline layer probably covers the granules and therefore does not allow FSH to work properly there. The granulosa cells also begin to regress slightly due to this. However, LH continues to be produced and released, which means that steroids are also increasingly formed in the ovary and thus increased Androgens (male sex hormones) are produced.
It is ultimately these that result in a further hyaline thickening of the ovary (ovary) and the typical cystic picture in the Ultrasonic be trained.

Furthermore, the male sex hormones to the often observed increased body hair (Hirsutism) and the increased amount of steroid to the obesity (Obesity).

The changed menstrual cycle is assigned on the one hand to the cystic changes, on the other hand to the disordered FSH / LH secretion.

diagnosis

The initial discussion between the doctor and the patient about the Medical history (Taking anamnesis) gives the doctor initial indications of the type of illness.
The timing and progression of symptoms can often make one suspect Polycystic Ovarian Syndrome let steer. In any case, if not already done, the further treatment and examination should be carried out by a specialist in gynecology, who will then usually identify the typical, cystic changes of the Ovaries (Ovaries). The picture ranges from completely inconspicuous Ovaries, to cystic structures arranged like a pearl necklace. Due to the increase in tissue, the ovary often appears enlarged on the ultrasound.

Symptoms

The typical symptoms of polycystic ovary syndrome are:

• Menstrual cycle disorders
• male hair type
• Mustache
• Hair loss
• oily skin
• acne
• enlarged clitoris
• Obesity (Obesity, in around 40% of those affected)
• infertility (in about 74% of those affected)
• Galactorrhea (Breast milk discharge)
• Diabetes mellitus
• increased miscarriage rate

Most of the time, the polycystic ovary syndrome is only expressed by some of the symptoms mentioned. Seldom does it know all symptoms at the same time. Some of the symptoms are seen in almost all PCO syndrome cases, while others are less common.

It often occurs due to Polycystic Ovarian Syndrome infertility, so that women with an unfulfilled desire to have children can develop a depressive mood in addition to the biologically related symptoms.

Can do that for a long time Polycystic Ovarian Syndrome to be present with no symptoms.
If it is still symptomatic, irregularities in particular occur Menstruation on. This results in either a lack of menstruation or an extended menstrual-free period.
If the menstrual break is between 35 and 45 days, a Stein-Leventhal syndrome be the cause. Sometimes it also happens Pelvic discomfort during or after menstruation.
Obesity (Obesity) and increased body hair (Hirsutism) are also observed at times. This is where the so-called male Hair type (Beard growth, pubic hair pulling towards the navel, chest and back hair). In extreme cases, a so-called Androgenization (Masculinization) are observed. These include the above-mentioned hirsutism, enlargement of the clitoris, reduction of the mammary gland, deep voice, masculinization of the body structure.

It can also be increased in part Hair loss and acne in patients with a PCO to be watched.

PCO pain

Some patients complain of abdominal pain, sometimes on one side, sometimes on both sides. The quality and frequency of pain can vary greatly, from persistent pain to brief, movement-dependent complaints, many other levels are possible.
The increase in circumference and size of the ovary due to the cysts can lead to pain, for example when pressure is applied to adjacent organs. Less often, the tearing or bursting of individual cysts can cause discomfort in the abdomen. The cysts can also twist on their stalk and become symptomatic. If the ovary twists and the blood supply is cut off, this manifests itself in severe pain, often in combination with nausea and vomiting, and represents a medical emergency. The pain sensation is different in every person and thus the pain tolerance also varies. It is important to listen to your body and, if necessary, seek medical advice in order to bring the discomfort and pain under control.

Is it possible to get pregnant?

In polycystic ovarian syndrome, the regular circulation of the menstrual cycle is disrupted, but the function of the ovaries is not necessarily impaired. Therefore, pregnancy is in principle possible despite PCO, even spontaneous onset of pregnancy has been described, albeit rarely.
The multiple cysts contain functional follicles, which are synchronized and stimulated with medical support and thus ovulation, i.e. ovulation, can take place. It is important to discontinue oral contraceptives, which are regularly used in the treatment of polycystic ovarian syndrome. Then the patient can undergo follicle-stimulating therapy, which is usually carried out with the active ingredient clomiphene. This triggers ovulation up to 80% of the time. The likelihood of pregnancy due to hormonal stimulating measures varies between 25-40%. The probability of a multiple pregnancy is increased.
Other possibilities of pregnancy in the case of polycystic ovarian syndrome are switching to an LH / FSH preparation or in-vitro fertilization (IVF). In general, if blood sugar irregularities are caused by PCO, the chances of pregnancy are increased by setting the sugar levels correctly using medication can.

therapy

The treatment of polycystic ovary syndrome (PCOS) has two goals:

1. Treatment tries to alleviate existing symptoms.
2. The metabolism should be normalized and thus long-term effects prevented (e.g. diabetes mellitus, cardiovascular diseases).

If a polycystic ovarian syndrome is diagnosed, it is primarily important to reduce the existing excess weight. To do this, it is recommended to change your diet and exercise more. This alone can usually achieve a regular cycle as well as regular ovulation even with polycystic ovary syndrome.

The measures used in further therapy are based on the wishes of the patients, in particular on whether or not they want to have children.

Without wanting to have children:

Polycystic ovarian syndrome (PCOS) causes typical hormonal disorders that can be treated with hormonal therapy, which is usually carried out with birth control pills.
However, this treatment for PCO syndrome (PCOS, polycystic ovarian syndrome) is only suitable for women who do not want to have children, as the preventive effect of the hormones would otherwise prevent conception.
The hormone preparation works against male hormones and thus helps to break the cycle of hormonal dysregulation. In addition, the therapy with the birth control pill also works against unwanted sequelae such as changed hair (hair loss on the head and heavy body hair), as well as the skin problems.

With the desire to have children:

For women who suffer from polycystic ovary syndrome (PCOS) but want to become pregnant, therapy with hormones that also have a contraceptive effect is not suitable. For this reason, these women are given low doses of cortisone supplements to reduce the production of male hormones in the adrenal gland. If the prolactin level (milk-producing hormone) is too high, it can be reduced with medication. If, in addition to the PCO syndrome (PCOS, polycystic ovarian syndrome), there is also an underactive thyroid (hypothyroidism), this must also be treated, since an unfulfilled desire to have children can also be due to an underactive thyroid.

If, despite this treatment of the polycystic ovary syndrome (PCOS, polycystic ovarian syndrome), a regular cycle does not set in, it is possible to induce ovulation with anti-estrogens (e.g. clomiphene).

If clomiphene is used unsuccessfully, the attending physician can also inject the follicle-stimulating hormone (FSH), but in a low dose.

This treatment increases the risk of a sudden, increased formation of follicles and thus the risk of high-grade multiple pregnancies.

The treatment of polycystic ovary syndrome (PCOS, polycystic ovarian syndrome) must be carried out with regular check-ups, which must be carried out at short intervals (sometimes daily).

In women with PCO syndrome (PCOS, polycystic ovarian syndrome), surgery can sometimes be a useful treatment option. The excess cysts are destroyed in a laparoscopy (laparoscopic) with heat or laser.

You can find more here Tips to get pregnant.

Also read our page Unfulfilled desire to have children.

PCO and metformin

If the blood sugar level is increased (which is often the case with polycystic ovary syndrome (PCOS)), the drug is used Metformin Suitable for lowering blood pressure, because it also stimulates ovulation and follicle formation.

We have published a completely separate topic on this subject under Metformin and PCO.

Therapy when trying to have children

The treatment of polycystic ovarian syndrome depends primarily on whether the patient has a Desire for children has or not.
If left untreated, a pregnancy difficult or impossible. If there is no desire to have children, androgen production in the ovaries can be reduced by the administration of ovulation inhibitors ("pill") Or Glucocorticoids (Cortisone) are inhibited.
In this case, ovulation inhibitors with the active ingredient cyproterone acetate are often used ("Diane"). This results in a compensatory inhibition of the androgen receptors and, through combination with ethinyl estradiol, a reduction in LH and FSH.
Aldosterone antagonists, how Spironolactone, inhibit the formation of Androgens and the development of androgen receptors and thus lead to a reduction in the symptoms described.

Exists a Desire for children, the presence of polycystic ovarian syndrome is a serious problem.
If the symptoms are pronounced, the administration of Clomiphene, Gonadotropins (HMG, FSH), Cortisone or comparable glucocorticoids or time-dependent administration of the gonatotropin-releasing hormone (GnRH) should be considered.
However, there is a risk that this will lead to so-called over-stimulation of the Ovaries comes what i.a. Multiple pregnancies may result.

prophylaxis

As the mechanism by which it develops is largely unexplained, prophylactic measures are still unknown.

forecast

Many disorders that affect androgen and hormone production are unfortunately chronic or not curable.
Patients with Polycystic Ovarian Syndrome must focus on one Long term therapy to adjust.
After a period of 9-12 months, the therapy should be adjusted accordingly and the medication should be increased or expanded.
Cosmetic treatments for the accompanying symptoms (shaving, epilation, Acne treatment) can also be useful. When taking the “pill”, acne infestation can also be reduced or completely eliminated.

Is there a cure?

A cure for polycystic ovarian syndrome (PCO syndrome) is unfortunately not yet possible.
There are only supportive measures that aim to reduce the symptoms and improve the quality of life of those affected. This means that the symptoms, i.e. the consequences of PCO syndrome, are combated, but not the cause, i.e. the disease itself. The treatment must be individually adapted in order to find the most effective therapy for the respective patient. In this way the symptoms can be brought under control or reduced. In some cases, the symptoms can even be completely eliminated. It is important to confide in a doctor who is familiar with the treatment of PCO patients and who has good expertise.
The agents that can be used to relieve symptoms include, for example, contraceptives (medication to prevent pregnancy). These can help with cycle irregularities, which are very common in polycystic ovarian syndrome. It is important to talk to the doctor about whether or not you are currently planning to have children in order to adjust the therapy accordingly. The preparations also have a preventive effect with regard to endometrial cancer, i.e. cancer of the uterine lining.
In particularly bad cases where the symptoms cannot be controlled, surgical measures are also treatment options. In the case of hirsutism, excessive body hair, contraceptives can also provide relief, as they better adjust the imbalance between male and female hormones. This is also true with regard to acne. If you are overweight, you should exercise regularly and change your diet. The active ingredient metformin is also often used in polycystic ovarian syndrome, as it interferes with the blood sugar balance and can normalize it. Metformin also curbs the production of male hormones, which can reduce acne, improve cycle irregularities and increase fertility.
It is advisable to undergo long-term treatment and regular check-ups in order to stop the progression of the symptoms and identify possible late effects at an early stage.
Despite a lack of healing prospects, some patients report having more regular menstrual cycles after a successful pregnancy, which makes further medical support for cycle control unnecessary. A new pregnancy can often be achieved more easily. Furthermore, many symptoms improve in some PCO patients with the onset of menopause.

Summary

Under a Polycystic Ovarian Syndrome (Stein-Leventhal syndrome), one understands a clinical picture caused by a hormonal imbalance, which usually becomes noticeable in the patients between the ages of 20 and 30.
Although the root cause until now largely unexplained is, it is assumed that the ovaries (ovaries) are made less sensitive to the hormone FSH by a hyaline layer, while the second hormone LH is still released in normal quantities. LH stimulates the production of male sex hormones, which leads to masculinizing characteristics such as male hair pattern, masculinization of the physique, clitoris enlargement and breast reduction but also hair loss can lead (Androgenization).
Often, however, women also become aware of the disease through the absence of the menstrual cycle or an extended break (between 35 and 45 days).
If left untreated, Stein-Leventhal syndrome can be a deliberate one pregnancy prevent.
In addition to a blood and urine test, in which the hormones should be checked and detected, the ultrasound examination of the specialist gives for gynecology often reflect the typical cystic appearance of polycystic ovaries.
Characteristically the ovaries appear like a string of pearls lined up. The type and timing of the complaints, which should be found out through the medical interview, also contribute to the diagnosis of PCO. The doctor should also rule out a tumorous cause of the symptoms and the so-called hyperthecosis ovarii before diagnosing a PCO.
The treatment depends on whether the woman wants to have children or not. If not, the symptoms can be tried with ovulation inhibitors ("pill“) As well as the administration of glucocorticoids (cortisone). If you want to have children, you can try to treat with clomiphene or gonatotropic administration at intervals. The danger, however, is ovarian overstimulation, which can result in multiple pregnancies.
If left untreated, pregnancy is difficult or impossible. Patients should be prepared for longer treatment. The success rates are moderate and sometimes require lifelong therapy. Additional cosmetic treatments can sometimes be helpful and, above all, alleviate the psychological components of the disease.
The latest studies have shown that patients with polycystic ovarian syndrome have an increased risk of insulin resistance (Diabetes mellitus) or cardiovascular diseases (heart disease, High blood pressure disease) to get sick.
An increased risk of malignant diseases of the uterine lining due to constant and irregular hormonal stimulation was also discussed.