Fertility

Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome (PCOS) is a hormonal condition that affects between 8-12% of Australian women. It is a condition where women have a combination of insulin resistance and elevated androgen levels.

The result is the development of multiple small, hormonally active follicles on each ovary, which perpetuate a vicious cycle of anovulation (which can make it difficult to fall pregnant), irregular periods and peripheral androgen effects like unwanted hair growth, skin pigmentation and acne. Some women with PCOS may also experience significant scalp hair loss, which can cause considerable stress for women.

At Women’s Health Melbourne, we understand the impact that Polycystic Ovarian Syndrome (PCOS) has on a woman’s life – and we can help you to make a big difference.

Diagnosing PCOS

Doctors typically diagnose PCOS when at least two of the following three symptoms are present:

  • 25 or more follicles are visible on one ovary in an ultrasound. (While older ultrasound criteria diagnosed PCOS with the finding of 12 follicles per ovary, advances in technology have improved the clarity of digital ultrasound images, providing doctors with a clearer image of the ovaries. Hence, >25 follicles per ovary is more appropriate)
  • Hyperandrogenism (clinical or biochemical), whereby high levels of androgens are present in the blood
  • Menstrual disturbance

A diagnosis of exclusion must also be made, whereby other causes for the symptoms have been ruled out before confirming a diagnosis of PCOS.

How Is PCOS Tested?

PCOS is tested by looking at the ovary via ultrasound and/or measuring the egg count chemically by measuring the Anti-Mullerian Hormone (AMH), which indicates the level of a woman’s ovarian reserve. Other hormonal tests may also be ordered to exclude other possible causes of menstrual disturbance and hyperandrogenism. Glucose tolerance and insulin resistance may also need to be investigated.

How Can PCOS Affect the Menstrual Cycle?

Some women with PCOS can have relatively normal menstrual cycles while others have no periods at all. Irregular ovulation and therefore irregular periods can also be a feature. While many women with PCOS can become pregnant spontaneously, getting the timing of sex right (around ovulation) can be frustratingly hard to predict without help.

The endometrium (lining of the uterus) is designed to shed regularly. Women with PCOS who do not regularly ovulate and go for a long time between periods are at risk of developing abnormal cells in the uterus known as endometrial hyperplasia. Women in this situation may be prescribed some form of regular progesterone therapy to protect their uterus, and thereby protect their future fertility. If left unchecked, endometrial hyperplasia in some women can progress to endometrial cancer.

How Can PCOS Affect Fertility?

PCOS can make it harder for a couple to conceive if a woman is not regularly ovulating (releasing an egg each month) or is not ovulating at all. In this situation, techniques of ovulation induction can restore normal fertility.

In women who are not yet trying to conceive, the uterus can be exposed to regular progesterone to protect it and preserve fertility for the future. Progesterone can be used in either the form of a Mirena intrauterine device (IUD), the oral contraceptive pill, NuvaRing, or oral or vaginal sequential progesterone options.

What Are the Treatment Options For PCOS?

PCOS is a complex clinical syndrome, and therefore treatment needs to be holistic. Aspects that contribute to a diagnosis of PCOS and factors to address include:

  • Genetics
  • Lifestyle
  • Hormonal changes (which can be exacerbated by obesity)
  • Increased androgens (male hormones), hirsutism (excess hair growth), and acne
  • Increased insulin, cardiovascular risk factors, diabetes/metabolic syndrome
  • Ovarian follicle dysregulation, increased estrogens, anovulation, endometrial hyperplasia
  • Psycho-social factors, including body image, self-esteem, depression and anxiety

For some patients, lifestyle change and weight modification may assist in treating some of the symptoms of PCOS. Some changes may include:

  • Diet and exercise changes
  • Body weight reduction of between 5-10%
  • Reducing BMI to <35 for fertility
  • Supportive/motivational counselling
  • Referral for bariatric/gastric sleeve surgery where weight loss cannot be achieved more conservatively

Treatment for excess hair growth (only suitable for patients who are not trying to conceive) may include the following:

  • Oral contraceptive pill and/or anti-androgenic progestogen
  • Sex Hormone Binding Globulin (SHBG) modification
  • Androgen receptor antagonists
  • Topical/cosmetic therapies
  • VANIQA cream (eflornithine hydrochloride)

Treatment for male pattern hair loss (only suitable for patients who are not trying to conceive) may include the following:

  • Combined oral contraceptive pill
  • Androgen receptor antagonists

Fertility treatments can include:

  • Cycle tracking
  • Ovulation Induction
  • IVF
  • Metformin (to reduce hyperstimulation risk and improve insulin sensitivity)

Our treatments address the different elements of PCOS simultaneously including:

  • Menstrual control and endometrial protection
  • Effective treatment of unwanted hair and skin breakouts
  • Successful weight management
  • Improvements in confidence and self-esteem
  • Fertility assistance when desired

Our model of care is to offer women with PCOS ongoing care and support.