Polycystic ovarian syndrome (PCOS) is a common cause of infertility and is  estimated to be present in over 20% of infertile women. PCOS usually presents with of a “cluster of symptoms, or a syndrome” rather than one specific clinical finding. Irregular or no ovulation is a common finding in PCOS patients.

PCOS Symptoms

PCOS patients have chronically elevated levels of androgens, which are male hormones including testosterone and others.  PCOS is commonly misdiagnosed unless a complete fertility workup is performed by a reproductive endocrinologist/infertility specialist.

Many PCOS symptoms are caused by excess androgens including irregular, or no, menstruation, excess body hair, lowering of the voice, obesity (thin women can have PCOS), a “pear shaped” body, and ovaries covered with numerous small cysts.

This cystic condition seen on the ovaries of patients with PCOS gives rise to the terminology “polycystic ovarian”. PCOS patients are also at much higher risk to develop diabetes or other long-term health problems such as cardiovascular disease.

In PCOS patients, the condition leading to excess androgen production is known as hyperinsulinemia, or elevated insulin levels.  The body’s cells do not respond normally to a “given amount” of glucose and they “over produce” insulin to compensate. This excess insulin drives the ovaries to increase androgen production and decrease serum sex hormone-binding globulin.

Polycystic Ovarian Syndrome, PCOS, Treatments

PCOS is often first treated with Clomid, however, metformin use has increased over the last several years. Clomid’s initial dose is 50 mg per day on cycle days 3-7 and a progesterone level is drawn on cycle day 21 to document follicular development.  If the level is > 5, the same dose of Clomid is continued and the patient is instructed to purchase a urinary LH ovulation detection kit.  If the progesterone level is low, menses is induced with Provera.  The vast majority of Clomid pregnancies will occur in the first 3-6 ovulatory cycles and Clomid therapy beyond this period is rarely recommended.

Metformin is often used to normalize ovulation in insulin resistant PCOS patients.  Metformin increases the cells sensitivity to insulin thus correcting hyperinsulinemia. The reduction in insulin reduces androgen production by the ovaries allowing ovulation to resume. If metformin alone is not effective, it may be used in combination with Clomid. 

If Clomid/metformin therapy(s) is not effective in treating the PCOS patient, the next treatment step may be ovulation induction with follicle stimulating hormone (FSH). These patients should always be treated by a reproductive endocrinologist fertility specialist with training in using injectable FSH.  PCOS patients are more likely to have exaggerated responses to fertility drugs that can lead to serious side effects including ovarian hyperstimulation syndrome. They must be carefully monitored and frequent dosage adjustments may be necessary.  A new medicine called Femara may also be useful in this group of patients.

Obese PCOS patients may resume ovulation after completing a weight loss program, however, it is very difficult for PCOS patients to loose weight because of hormonal imbalances. A low carbohydrate approach seems to work best and patients are encouraged to seek the counsel of a nutritionist.

Finally, in young patients with PCOS, who have an exaggerated response to fertility drugs, multiple births can be a large risk.  In these situations, the reproductive endocrinologist, fertility specialist will often recommend IVF in order to control the number of embryos placed into the patient’s uterus.  This can give an excellent pregnancy rate while limiting the number of high order multiple births.

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