Polycystic Ovary Syndrome (PCOS) & Fertility
As many as twenty five percent of women of childbearing age have PCOS, but most don’t even know that they have it until they begin trying to get pregnant.
Advice from a PCOS expert
How to cope with PCOS - Fertile Minds video
My name is Robert Lahoud, I'm a fertility specialist and reproductive endocrinologist, and I work as the clinical director at the IVF Australia North Shore Clinic.
How to cope with PCOS on a day-to-day basis. First of all, there are several symptoms that are associated with PCOS. One of them may be excessive facial and body hair. This is called hirsutism, and the symptoms obviously can be quite difficult to manage. In the short-term, we recommend cosmetic treatments such as electrolysis and laser.
Long-term hormonal preparations, such as the combined oral contraceptive pill, and anti-androgens such as Spironolactone and Subrata acetate are very good options that managing this condition, you do need to see a specialist or your GP about this to get these medications prescribed.
With regard to acne, which is also very common. We often use similar, very similar treatments. They're obviously topical treatments like face washes, that can be effective. You can take topical antibiotics from time to time. And then you've got the hormonal preparations that I mentioned before, such as the combined oral contraceptive pill and the anti-androgens that help to manage their condition over time. And if the acne is very, very bad, especially cystic acne, then it's good to maybe see a dermatologist who might recommend the use of raw Accutane, which is very effective, important to say that while people are on raw Accutane, they're not allowed to fall pregnant because it is teratogenic. So it's really important to have some form of contraception at the time.
In regards to irregular periods, and these are very common in patients with PCOS, and they're related to irregular or absent ovulation and these can sometimes be very heavy, painful and unpredictable, which makes life very difficult. Often we use hormonal treatments like the combined oral contraceptive pill to change this. And this is really important because it can also reduce the long-term risk of cancer of the uterus, which is slightly increased in women with irregular periods. So this is, again, you probably need to see your specialist or GP about this to have this treatment started.
With regard to weight gain. Weight gain can be part of Polycystic Ovary Syndrome. And there are many reasons for why people gain weight. It doesn't always just have to be the PCOS, but certainly if you have PCOS there's certain strategies that we try to use to help, to lose the weight and look to just be really fit, which is what I always talk to my patients about. To be fit you should exercise a bit and generally be very healthy with your diet. So healthy choices, regular meals is often what we recommend. There are some medications that could be also used to help with weight management.
But look, I think the most important thing is not to target the weight, but to look at a healthy lifestyle at the end of the day, if you live healthy and your weight is a certain weight, then you probably are healthy. Even though the weight might not be exactly what everyone would like you to be. So that's a much more achievable goal. So whatever we do, it has to be sustainable and achievable. And so a healthy lifestyle, if you follow that, that's really the best way to manage PCOS and your weight.
So with regard to emotional implications. The symptoms of hirsutism, acne and the irregular periods, and sometimes the decreased fertility can be emotionally difficult to handle. And so it's really important to seek support. That support can be by finding good sources of education about PCOS by speaking to your doctor, seeking help from a psychologist too. So all of these things can really help to get you through this. It's always important to remember, as you understand your condition and you manage it, everything can be overcome and we can manage the symptoms and really help you with whatever we need to help you with.
So with regard to long-term health implications, there are two main ones. One is, there's a high risk of diabetes in women who have PCOS. And this is particularly increased in women who are overweight and obese. So lifestyle with a good diet and exercise regime is really, really important. Medications, such as Metformin can be used and make the onset of diabetes less and delay it, which is a really important thing. The other treatments and for diabetes obviously, would be more handled by an endocrinologist such as use of insulin if that was required in the future. But in the short term, a good lifestyle with potentially the use of Metformin is what we commonly recommend.
With regard to the other long-term health implication. That is a high risk of getting endometrial cancer, cancer of the uterus, which is increased in women with irregular menstrual cycles. In that case, often we recommend the long-term use of the combined oral contraceptive pill to regulate the hormones and the effect on the uterus.
So with regard to conceiving, if you have PCOS. There are several treatments, so from a hormonal point of view, the number one treatment now is called Letrozole. It's a simpler tablet where patients take five tablets of this Letrozole in the beginning of their menstrual cycle. And as a result about 75% of women start to ovulate very regularly. And the pregnancy rates are really good. And a lot of women do conceive with this treatment.
If this is not effective, then we do have other medications. One is a drug called Clomid or clomiphene citrate, which we sometimes use. If the Letrozole doesn't work, it's a side of the older medication. It's the one we used to use, but it's something we can still find useful in some patients. And then there are more advanced treatments like injections with a hormone called FSH, Follicle Stimulating Hormone. That is very effective. If you use that, you nearly get a hundred percent chance of ovulation and these drugs are much more difficult to administer because they injections. Furthermore, we need to monitor the progress very carefully because they're associated with a high number of multiple pregnancies, if you don't watch. So we watch these patients in our clinic with regular blood tests and ultrasound, really careful that they don't produce too many eggs or follicles to keep the number of multiple pregnancies down.
And IVF is a alternative treatment, which is really a second line treatment. If the other treatments have not worked. And with IVF, we stimulate the ovaries to make lots of eggs. We harvest those eggs with an ultrasound based procedure, make them into embryos. And, the chances of this working for women with PCOS is generally very, very good.
We only use this if it's needed, and really we would aim for more natural therapies, even some simple medications first in the hope that that's successful.
If you've been diagnosed with PCOS in the past, and you've used the combined oral contraceptive pill for some time, your symptoms that you had originally, are being masked by the oral contraceptive pill. Now, when you come off the pill to maybe become pregnant, or because you want to have a break, it's really important to see, and because your symptoms might be different now from what they were before and your periods that used to be irregular could be quite regular. And from a fertility point of view, it may mean that you're actually quite fertile at that stage.
So it's really important to understand that things are not always the same and they can actually improve over time. So normally what I would do is stop the pill, wait for two or three months to see how things go, keep a record of it. And if it's still irregular periods or the skin gets bad, then definitely seek medical help.
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What is Polycystic Ovary Syndrome? (PCOS)
PCOS (Polycystic Ovary Syndrome) is a common hormone problem that can affect fertility and make it more difficult to have a baby. It’s a combination of having polycystic ovaries, as diagnosed on an ultrasound scan, with symptoms of a hormone imbalance such as irregular periods or male hormone side-effects such as abnormal hair, acne or weight gain.
What exactly are polycystic ovaries?
Polycystic ovaries occur when a high number of eggs can be seen on an ultrasound scan. Each egg reveals a small dark circle on the ultrasound scan, giving the appearance of multiple cysts, hence the name. However, there are actually no “cysts” at all, it’s just a high number of eggs that are present.
What causes PCOS?
The exact cause of PCOS is currently not known. Several factors may influence the onset of PCOS, including genetics.
Higher levels of androgens, or ‘male hormones’, are present in women with PCOS. These high amounts of hormones can prevent ovaries from releasing an egg during each menstrual cycle, and can cause extra hair growth and acne, which are consistent symptoms of PCOS.
Higher levels of insulin are also present in women with PCOS. This hormone controls how the food you eat is converted into energy. Many women with PCOS also have insulin resistance.
Symptoms of PCOS include irregular periods (or no periods at all), increased hair growth, acne, obesity and difficulty falling pregnant. You might experience very heavy yet infrequent periods, along with pain, bloating and tenderness.
Imbalances in hormonal production affect ovulation, which may occur irregularly or not at all. There may also be a mild increase in testosterone levels, causing darker and thicker hair growth and acne.
Hormonal imbalances also cause problems with sugar metabolism, leading to weight gain - and a higher risk of gestational diabetes if you fall pregnant.
- Irregular period (or no period at all)
The hormone imbalance can prevent release of the eggs so that the periods become either very irregular or, in some cases, stop altogether.
- Hair growth and loss
The hormone imbalance leads to slightly more male hormone being released. This can cause hair to grow in unwanted places, or alternatively, thinning hair and hair loss.
- Weight gain
Hormonal imbalances also cause problems with sugar metabolism, leading to weight gain - and a higher risk of gestational diabetes if you fall pregnant. You may put weight on easily or find it harder to lose. If you are concerned you’re overweight for your height - calculate your BMI.
- Difficulty falling pregnant
PCOS makes it harder to conceive due to lack of ovulation. Some women may occasionally ovulate and some never do. Simple ovulation checking with a single blood test in the second half of your cycle is a good place to start if you’re not sure. If your periods are far apart or non-existent, you’re probably not ovulating and therefore have no chance of conceiving without treatment. This is very easy to sort out with simple medications, so seek medical help early.
What are the long term risks of PCOS?
Very variable. Most women with PCOS have no long-term effects but there is an association between PCOS and metabolic problems linked to insulin resistance and some women can be affected by this. When a woman is diagnosed with PCOS, she should also have her metabolism tested and followed up over the years. It is also important to ensure that young women with PCOS have medication to ensure that they have regular periods, otherwise overgrowth of the lining of the uterus, called hyperplasia, can cause problems in later life.
Are polycystic ovaries always bad?
No. Where the only feature is polycystic ovaries and there are no symptoms and no hormone imbalance found on testing, there is no syndrome. Polycystic ovaries on their own are not serious and, in some cases, can provide reassurance that there are still plenty of eggs available for future fertility. If there’s no hormone imbalance, there’s no need to worry about any of the problems below.
How does PCOS affect my fertility?
The symptoms of PCOS including irregular or no periods, along with a documented increase in the risk of miscarriage, mean the chance of getting pregnant naturally is low if you have PCOS, and you should seek medical support.
It is important to remember that the presence of polycystic ovaries is not always bad news. Many younger women can have severe side-effects from the syndrome caused by the hormone imbalance associated with polycystic ovaries. However, as women age, the follicle number drops and the hormone imbalance corrects itself.
The result is that women who suffer polycystic ovary syndrome in their teens and twenties can sometimes end up having more eggs in their thirties without the syndrome and therefore a better chance of conception.
PCOS Fertility Treatment
There are a number of options available, depending on the main issue you are experiencing.
Weight loss can be more difficult because of the higher levels of testosterone, but it has a very beneficial effect on balancing hormones and restoring regular periods in obese women. So exercise and a change of diet could have a significant impact.
Insulin sensitisers, such as Metformin, reduce the impact of insulin resistance and can also assist in weight loss.
Ovulation inducing drugs such as Clomiphene (Serophene or Clomid) can stimulate the ovaries.
If you do not respond to Clomiphene, injectable drugs (FSH) can be used, but these require specialist facilities and close monitoring of the response to avoid severe side effects and multiple pregnancies.
IVF treatment may sometimes be necessary in very difficult situations but is not usually required.
Diagnosis of PCOS
Testing for PCOS can include an ultrasound scan, which can indicate the presence of many small follicles.
Blood tests can reveal changes, with higher levels of testosterone and LH (often in conjunction with a higher LH to FSH ratio) than women with normal cycles. These levels may vary considerably and are best assessed early in the menstrual cycle (if there is one). Blood tests may also indicate a change in blood glucose and insulin levels.
Where can I get help managing PCOS?
If you are experiencing any of the above symptoms and you would like help managing them, IVF Australia runs regular PCOS clinics at our Greenwich clinic and Westmead Clinic for women wanting more information on the diagnosis, assessment and management of PCOS. Please contact the clinics directly for more information or book an appointment with a PCOS fertility specialist.
The Polycystic Ovary Syndrome Association of Australia Inc (POSAA) is a ‘self-help’ association for women with PCOS and those who suspect they have it. The Association brings together sufferers, their families and friends, and medical professionals interested in supporting the group and PCOS patients.
The Association’s overall purpose is to offer support to women with PCOS, promote understanding and awareness of the syndrome and encourage research into PCOS. POSAA is proud to have been instrumental in the formation of the PCOS Australia Alliance and the subsequent launch of world-first guidelines for the diagnosis and care of women with PCOS. For more information, visit the POSAA website.
If you know or suspect you have PCOS and have been trying to conceive for more than 12 months (6 months if you are over 35) please call 1800 111 483 or book an appointment with a fertility specialist.
Appointments are available in the next couple of weeks and will cost approximately $150 for a couple after the Medicare rebate.