PCO or PCOS

Name:
The name is a bad name! Poly Cystic Ovarian Syndrome, or Disease, or simply Polycytic Ovaries is a bad name. It implies that there are many cysts in the ovaries. And this is not quite true.
 
An ovarian cyst is a large collection of fluid in a sac inside the ovary, that may be benign or malignant (rarely). Ovarian cysts (true cysts) usually are removed by surgery.
In PCO, there are no 'cysts' in the ovaries. Only too many follicles (eggs) that neither grew to become mature eggs, nor died off.
 
Normal Hormonal Patterns:
Each month, a very complex chain of events happens that end up with ovulation. First FSH rises to 'wake the ovary up' and 'tells it to make an egg". From the pool of many small eggs, one picks up the signal from FSH and starts outgrowing its peers. This egg will now produce Estradiol hormone, E2. When the E2 has reached a critical level, LH peaks and leads to 'release' of the growing egg: Ovulation. Progesterone (P) will now start rising. Progesterone will prepare the uterus for the fertilized egg to implant and start a pregnancy.
If the eggs does not get fertilized, it dies off, the hormonal pattern changes, and E2 and P levels go down and menstruation starts, and a new cycle begins.
 
Abnormal Hormonal Pattern:
For a reason that is not quite clear to us, this very well orchestrated chain of events loses its tune. LH remains high and FSH does not rise well. The ovaries get confused, and eggs do not know what to do, so many of them try to grow, but fail to mature, and yet again, fail to die. We end up with a bunch of small eggs half grown in the ovaries (poly cysts), testosterone like hormones levels increase and progesterone function is lost. This leads to the clinical presentations.
 
Clinical Presentations:
Are based on the problems of abnromal hormones. Ovulation is not regular, so periods are not regular. Pregnancy may be difficult, or delayed.
The loss of progesterone may have some thickening effects on the lining of the uterus (something than needs to be avoided or treated).
The high male hormones levels may lead to increased body hair, oily skin and increased acne.
Not all features may be present in call cases.
There is another group of presentations that may be present with PCO, and this includes:
more than average weight, certain picture of fat distribution, dark patches of skin in certain areas (e.g. back or neck, arm pits, inner thighs).
There is usually an increase in body weight at time of puberty or a couple of years after that, and then the picture starts unfolding as above.
Causes:
So what casues PCO? We do not know. There is the observation of weight gain at time of puberty. There is observation of high LH hormone. There is the observation that it is more common in families with history of Type 2 Diabetes.
Treatment or Management:
Yes, you guessed it right. If we do not know what causes it, how can we treat it?
Well, the treatment, or better, the management, depends on what we want at this point in time.
If no pregnancy is desired in the near future, birth control pills (BCP) are the best option. They lower LH and male hormones, correct their effects on the skin (may take a long time for hair to go away), and more importantly, bring on regular menstrual cycles. Both monthly and three monthly pills are OK (Marvelon or Seasonique). Very low dose pills (Alesse, Alyssina, etc) are not a great option
If pregnancy is desired, we start fertility treatments (may include induction of ovulation by pills or shots, may include short term use of BCP, may include Sperm Wash, etc, and up to IVF).
In all cases, you need a treatment to prevent the build up of the inside lining of the uterus. BCP is an option, Provera or Progesterone is an option. Interestingly, Mirena (IUD) is a good option for those who do not want to get pregnant soon.
Metformin is a medication used in treatment of Type 2 Diabetes. It has been shown to be effective in treatment of PCO, especially if we want to get pregnant. You will need to continue on with Metformin when you do get prgenant and up to alt least 20 weeks pregnancy.

© 2016 by Dr Abdel Hadi

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