Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders, and affects between 6-7 percent of reproductive aged women. PCOS is a constellation of symptoms—a syndrome—characterized by:
- menstrual irregularities (infrequent or absent ovulation with a variable bleeding pattern)
- elevated androgens (high testosterone) or symptoms of elevated androgens (ie. acne, excess facial hair growth, thinning hair)
- “polycystic-appearing” ovaries on ultrasound
Obesity and diabetes (or pre-diabetes) are also often associated with PCOS. However, because PCOS is a syndrome and not a specific disease, not every patient with PCOS will present with all of its symptoms. Women may have only irregular periods and facial hair growth, or they may be thin with acne and absent ovulation. It is important to realize that not every person with PCOS has the same symptoms, and this can make it difficult to diagnose.
PCOS is also a diagnosis of exclusion, meaning that all other causes of the above symptoms must be ruled out before a diagnosis of PCOS can be given. These other etiologies include thyroid dysfunction, prolactin disorders, hypothalamic dysfunction (secondary to stress, eating disorders, extreme exercise, systemic illness or unknown causes), enzyme disorders and testosterone secreting tumors.
After being studied for over 70 years, it is now well-known that patients with PCOS have increased risk for many long-term health complications including diabetes, high blood pressure, cholesterol abnormalities, cardiovascular disease, endometrial cancer and liver disease (nonalcoholic steatohepatitis). Early diagnosis and treatment may help to reduce some of these risks and therefore is of the utmost importance.
PCOS treatment is targeted at the various symptoms and depends on each patient’s needs.
Diet and exercise can be very helpful in treating PCOS as they can help with weight loss, which can sometimes result in normal ovulation and can also help in reducing some of the long-term complications mentioned above. Birth control pills, other hormonal contraception or monthly progesterone helps by protecting the uterus from overexposure to estrogen and preventing abnormal growth of the uterine lining. In addition, hormonal contraception can help regulate the hormonal imbalances that exist and improve symptoms like acne and unwanted facial hair growth. Other medications, electrolysis, or laser therapy may also be useful PCOS treatment in cases of severe hirsutism. Insulin sensitizing agents like metformin can improve insulin resistance and even help some patients to ovulate spontaneously.
PCOS AND FERTILITY
For PCOS patients who need fertility assistance, ovulation induction with medication is the primary therapeutic goal. Oral medications (ie. clomid, letrozole/Femara) are typically used as first-line therapy. However, because not all patients will ovulate in response to these medications, injectable gonadotropin hormones (ie. Follistim, Gonal -F, Bravelle, Menopur) may be necessary. Approximately 80% of women with PCOS will ovulate with clomid and approximately 50% will eventually conceive.
Primary Ovarian Insufficiency
Primary ovarian insufficiency (POI), also known as premature ovarian failure, is classically defined as ovarian failure before age 40. It occurs in 1% of all women. And it is associated with the cessation of menstrual cycles or very irregular cycles, estrogen deficiency symptoms (i.e., hot flashes, vaginal dryness, decrease in sex drive) and elevated follicle stimulating hormone (FSH) in the menopausal range.
Several lab tests are performed in order to evaluate a patient for POI and rule out other etiologies. These include:
- Follicle stimulating hormone (FSH) and estradiol levels
- Pregnancy test (to rule this out as a cause of the menstrual irregularities)
- Prolactin (to determine if an elevation in this hormone is the cause)
- Thyroid stimulating hormone (TSH) levels (to rule out thyroid disease as the cause)
Once the diagnosis is made, other lab tests will be ordered to complete the work up. Because POI is often associated with other autoimmune disorders, tests to evaluate for possible thyroid disease (found in about 30% of POI patients), diabetes (found in about 5%) and adrenal insufficiency (found in about 3%) should be done. Genetic abnormalities are occasionally the cause of POI (more frequently in the case of women who never went through puberty and started having periods than in women who did), and a karyotype should be performed to evaluate for Turner’s syndrome/mosaicism as well as genetic analysis for the Fragile X pre-mutation.
Once diagnosed, a woman with POI should be given hormone replacement therapy in order to treat the consequences of short and long-term estrogen deficiency. Hot flashes, vaginal dryness, fatigue and moodiness are all symptoms of new onset estrogen deficiency and can be improved with estrogen replacement. In addition, women with POI have increased risks for future osteoporosis and osteopenia, especially young women who develop POI before they reach peak bone density. Estrogen therapy should be started as soon as possible in order to prevent this bone loss.
POI and Fertility
Although “ovarian failure” implies that the ovaries do not work at all anymore, approximately 5-10% of women with POI may have intermittent ovarian function including ovulation that can result in pregnancy. Despite this fact, however, women with POI who wish to become pregnant are generally counseled to consider donor egg/IVF because women with POI are not easily stimulated with oral medications or injectable hormones to produce eggs on their own. The best option for pregnancy for women with POI is in vitro fertilization with donor eggs in women with POI has been associated with pregnancy rates of up to 50-60% per cycle.
The goal of reproductive surgery is to correct defects, both acquired and congenital, and to restore anatomy, allowing for normal sexual and reproductive function. Both Dr. Koopersmith and Dr. Landay have completed extensive training to achieve expertise in performing these procedures.
Minimally invasive techniques are used whenever possible, and include laparoscopic and hysteroscopic procedures. Laproscopy is a procedure that allows us to look inside the abdomen with a telescope inserted through a small incision in the umbilicus. We are able to visualize scarring/adhesions, endometriosis, ovarian cysts, and blocked fallopian tubes that can all be the cause of infertility. After diagnosing the problem, additional instruments can be inserted to surgically correct or remove any abnormalities. Opening or removal of the fallopian tubes, resection of endometriosis or removal of fibroids is often performed laparoscopically.
Hysteroscopy, or visualization of the inside of the uterus with a telescope placed through the cervix into the uterus can be performed either in our office or in an outpatient surgery center depending on the extent of the procedure. Diagnostic hysteroscopy allows us to visualize the inside of the uterine cavity to determine if it is normal or if there are conditions such as polyps, fibroids, scarring or congenital defects that can contribute to infertility or miscarriage. When found, these uterine conditions can be corrected directly through the hysteroscope.
Occasionally, the problem is too extensive to be corrected with laparoscopy or hysteroscopy, and an open procedure is necessary. In these cases, a larger incision in the abdominal wall, or laparotomy, is performed allowing for greater ability to correct the defects. Removal of uterine fibroids, extensive pelvic scarring, or large ovarian cysts or difficult tubal surgery is often performed by this technique.
At the Valley Center for Reproductive Health, we perform a variety of reproductive surgical procedures using both traditional and robotic laparoscopy (www.davincisurgery.com), hysteroscopy, or laparotomy including:
- Myomectomy: removal of uterine fibroids
- Polypectomy: removal of uterine polyps
- Ovarian cystectomy: removal of ovarian cysts
- Salpingectomy: removal of one or both fallopian tubes (usually because of damage that cannot be repaired)
- Salpingostomy: making an incision in a fallopian tube either to repair a closed tube or to remove an ectopic pregnancy
- Tubal ligation: separating a fallopian tube from its attachment to the uterus (performed in lieu of salpingectomy in specific cases prior to performing IVF)
- Tubal ligation reversal: rejoining of segments of the fallopian tubes that were separated by tubal ligation in the past
- Metroplasty: removal of a uterine septum
- Vaginal septoplasty: removal of a vaginal septum
- Lysis of adhesions: cutting and removal of scar tissue
- Oophorectomy: Removal of the ovary (one or both)
- Hysterectomy: removal of the uterus, either complete (removing the cervix as well) or supracervical (leaving the cervix behind)
Schedule a Consultation
Take the first step toward parenthood and schedule a consultation with one of our highly trained fertility specialists. Drs. Koopersmith and Landay are available to answer any question you may have and help you achieve your dream of having a healthy baby. Follow this link to fill out a short contact form and we will be in touch with you shortly to schedule a consultation. We look forward seeing you soon.