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POLYCYSTIC OVARIAN SYNDROME - HIRSUTISM

What is Polycystic Ovarian Syndrome ?

All women produce both female and male hormones. The female hormones oestrogen and progesterone come mainly from the ovaries and regulate the menstrual periods. Some male hormones (androgens) also come from the ovaries, although rather more are made by the adrenal glands, one of which sits near the top of each kidney. Androgens keep muscle, bone and skin in good shape and also contribute to libido. They also regulate hair growth and grease content of skin. In polycystic ovary syndrome, (PCOS) the level of androgens is slightly higher than normal. In some cases the skin is also rather more sensitive to their effect. As a result, body and facial (especially upper lip) hair may grow rather faster than usual and appear thicker. In contrast, androgens cause thinning of scalp hair, but baldness is extremely rare in PCOS. The greasiness of the skin may lead to grease-duct blockage, and when infected, acne results. In most women, monthly release of the egg (ovulation) does not occur regularly in PCOS : the oestrogen/progesterone cycle is disturbed. Irregular or absent periods are common, but not invariable. Fertility tends to be reduced.

How does Polycystic Ovarian Syndrome occur ?

The cause is still unknown. Failure of the egg to be released regularly each month is responsible for the development of cysts, which then enlarge the ovaries. Androgens are made in the walls of these cysts. The levels may be further stimulated by another hormone (called LH) which comes from the pituitary gland behind the nose, at the base of the brain. In a few cases, the problem results from an abnormality of the adrenal gland, either due to an inborn fault in the production line of its hormones, or to overproduction from a tumour of this gland.

Why does Polycystic Ovarian Syndrome occur ?

Almost 1 in every 10 women have this condition in some form or other. It is to some extent inherited. Gaining weight worsens the hormone imbalance, hair growth and the menstrual irregularity. Being below ideal weight can also turn off your periods in PCOS. Many forms of contraceptive pill contain a progestogen which has a slight male hormone effect. In people with appropriate tendency, this can aggravate (although rarely cause) hirsutism. A link has been shown between PCOS and a tendency to mild diabetes and abnormalities of blood fat levels. In PCOS, the hormone insulin is not so good at lowering blood sugar, but for some reason stimulates extra androgens to be made by the ovaries.

Treatment Involved for Polycystic Ovarian Syndrome

Diagnosis is not usually difficult. The important decision for your doctor is to rule out an adrenal cause or other ovary problem. Both of these are uncommon. Blood, and occasionally urine tests are done. Often an ultrasound test is done, either on the abdominal wall, or if better pictures are needed, using a small probe in your vagina. This test uses high frequency sound waves to picture the size and structure of the ovaries. The problem will usually have begun in teenage years, but it is quite unusual for it to get much worse beyond the age of 30. For the hair growth, cosmetic treatment is always the first approach. Bleaches, plucking or trimming with scissors may be enough: waxing or electrolysis may be necessary. Contrary to popular belief, shaving does not affect either the thickness of hair or the speed with which it grows. Laser treatment is being increasingly used and appears to be effective : however, the longer term effects on treated skin are not clear.

Acne can be dealt with by using sulphur-containing ointments or certain antibiotics of the tetracycline group. The drug isotretinoin is sometimes highly effective. Correcting the hormone imbalance is not always easy or successful. Weight loss (if necessary) is worth a try. This will reduce androgen levels and probably make the periods more regular. Certain types of the contraceptive pill (Dianette, Marvelon, Mercilon) contain a progestogen without androgenic actions. They may help both the hair growth and the acne. Other types of contraceptive can worsen these problems. The oestrogen content of the pill turns off the LH production from the pituitary and also makes the skin less sensitive to androgens. This approach to treatment has the additional advantage of regulating any irregular periods. Anti-androgens block the effect of androgens on the skin. They work well in some people. Spironolactone (Aldactone), cyproterone (Androcur), flutamide and finasteride are the main ones used, and are often given together with the pill to avoid irregular periods. Sometimes, drugs which lower insulin and sugar levels are used. Of these, metformin and a group of drugs called glitazones have been assessed. They have been shown to improve the hormone pattern, regulate periods and improve fertility. Benefits on hair growth have not been well proven. Some patients will be treated with steroids (cortisone-like drugs), particularly if an adrenal factor has been shown to be present by the necessary tests. Fertility problems may respond to weight loss alone. The ovulation tablet clomiphene (Clomid) is successful in up to 75% of people. It is taken as 5 day courses every month. If this fails, other forms of ovulation assistance can be used. If these fail, operations on the ovary can be done. Partial removal, laser vaporization or drilling will sometimes restart ovulation, although benefits on the hormonal imbalance are short-lived. Exactly how these treatments work is still unknown. Overall, more that 90% of infertility can be treated successfully.

During Treatment for Polycystic Ovarian Syndrome

With most hormonal treatments, greasiness of your scalp or face improves first, with the acne showing improvement in a few weeks. Abnormal hair growth may take 4 to 6 months of treatment before changes are noticed. It takes this long for the hair follicle to change from the thicker (terminal) to the finer (vellus) type hair production. Although acne is often responsive to treatment, less than half the patients treated will have little or no improvement in their hair problem. It is necessary to come to terms with the fact that some hair growth is almost certain to remain. Side effects from the drugs used do occur, including nausea, cramps, breast tenderness, rash and irregular bleeding. All anti-androgens must be stopped before considering pregnancy. They can affect sexual development of the embryo.

After Treatment for Polycystic Ovarian Syndrome

Good electrolysis does not scar, but occasionally marks are left, especially by non-expert operators. The types of contraceptive pill used are usually safe, but the doctor will check blood pressure a month or two after starting: it may rise. After stopping the contraceptive pill, periods may become irregular. This is not due to the pill, but to the underlying problem. Ovarian operations quite often are followed by adhesions of the bowel, which can cause pain and other symptoms. There are no long-term studies of the effects of laser treatment on the skin.

If Polycystic Ovarian Syndrome is Left Untreated

Your hair growth might worsen, although this is unusual beyond the age of 30, at which stage skin changes tend to become mnore stable.. No physical harm comes from having the minor hormone disturbance which causes the hair growth or acne. Although there is a natural fear of becoming more male in appearance and outlook, this is not the case. If you are not having periods at all, the lining of the womb (endometrium) can build up, risking the development of endometrial tumours. The problem can be largely avoided by regular hormone treatment to induce menstrual loss. There may may be a greater risk of developing diabetes and blood vessel disorders like heart attacks in later life. This may be a reason to use metformin and similar drugs, which should reduce these risks as well as lowering androgen levels. If youy remain overweight, you are certainly not helping any of the aspects of your condition.

Effects on Family of Polycystic Ovarian Syndrome

This condition quite naturally causes embarrassment and self-consciousness in many people. Coming to terms with it is not always easy, but discussing the problems with a close friend or family member may often be helpful.