Sunday September 18, 2005
It’s all in the ovaries
In addition to fertility problems fertility, polycystic ovarian syndrome (PCOS) can affect insulin production, heart, blood vessels, and even her appearance.
VERON, 32, from Kuala Lumpur, has never had a regular menstrual cycle. At times, she would go for five to six months before she gets her period. “I knew when I was a young teenager that getting pregnant wasn’t going to be easy for me because I didn’t have regular periods. Sometimes it would skip five or six months.
“I spoke with my doctor a few times during those ‘early’ years and I was always reassured that when I wanted to start a family, it wouldn’t be a problem. I thought, ‘Okay, so I will probably have to take a pill a month or so before I want to get pregnant.’”
However, when she settled down in 2000 at the age of 27 years old, she found herself struggling with infertility. She had seen many doctors who would give medication to induce her menstruation and ovulation, but she was still unable to conceive. After five years of struggling, she was finally diagnosed with polycystic ovarian syndrome (PCOS) early this year, after she had a full work-up at a fertility centre.
According to Dr Mahes Sittampalan, a consultant obstetrician and gynaecologist and a committee member of the Malaysian Society for Assisted Reproductive technology (MSART), polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, affecting an estimated 5 to 10% women of reproductive age.
For women trying to conceive a child, PCOS is a serious, common cause of infertility – nearly half of all female-factor infertility cases can be traced to PCOS.
Apart from affecting a woman’s menstrual cycle, fertility, and hormones, PCOS is a health problem that can affect insulin production, heart, blood vessels, and appearance. Women with PCOS have these characteristics:
High levels of male hormones, also called androgens
An irregular or no menstrual cycle
May or may not have many small cysts in their ovaries(cysts are fluid-filled sacs
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Many women with PCOS have a problem with weight |
Many women with PCOS have a weight problem. So researchers are looking at the relationship between PCOS and the body’s ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches, and other food into energy for the body’s use or for storage. Since some women with PCOS make too much insulin, it’s possible that the ovaries react by making too many male hormones, called androgens. This can lead to acne, excessive hair growth, weight gain, and ovulation problems.
The ovaries are two small organs, one on each side of a woman’s uterus. A woman’s ovaries have follicles, which are tiny sacs filled with liquid that hold the eggs. These sacs are also called cysts. Each month, about 20 eggs start to mature, but usually only one becomes dominant. As the one egg grows, the follicle accumulates fluid in it. When that egg matures, the follicle breaks open to release the egg so it can travel through the fallopian tube for fertilisation. When the single egg leaves the follicle, ovulation takes place.
In women with PCOS, the ovary doesn’t make all of the hormones it needs for any of the eggs to fully mature. They may start to grow and accumulate fluid. But no one egg becomes large enough. Instead, some may remain as cysts.
Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman’s menstrual cycle is irregular or absent.
Some of the symptoms of PCOS include:
Infrequent menstrual periods, no menstrual periods, and/or irregular bleeding
Increased growth of hair on the face, chest, stomach,back, thumbs, or toes
Acne, oily skin, or dandruff
Pelvic pain
Weight gain or obesity, usually carrying extra weight around the waist
Type 2 diabetes
High cholesterol
High blood pressure
Male-pattern baldness or thinning hair
Patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
Skin tags, or tiny excess flaps of skin in the armpits or neck area
Sleep apnoea – excessive snoring and breathing stops at times while asleep
There is no cure for PCOS, though it needs to be managed to prevent problems. Treatments are based on the symptoms each patient is having and whether she wants to conceive or needs contraception.
The main fertility problem for women with PCOS is the lack of ovulation. Some women with this disorder will ovulate (release a mature egg) occasionally, others do not ovulate at all. The good news is that pregnancy rates are high for women with this condition. The large majority will be able to have a baby, if they will undergo treatment. Many will be able to get pregnant using fertility hormone pills to induce ovulation. About 75% of women with polycystic ovaries will ovulate with clomiphene, but only about 40% will get pregnant with it.
If this fails after about six to nine ovulatory cycles, the next step is usually injectable gonadotropins. About 90% of women who do not ovulate with clomiphene will ovulate with this medication. The majority will get pregnant as well.
If this fails after about three to six ovulatory cycles, the next step is usually in vitro fertilisation. Veron is now 12 weeks into her first pregnancy after undergoing IVF treatment, in which she managed to produce 22 eggs after stimulation, out of which 18 were fertilised.
For women who don’t want to become pregnant, birth control pills can regulate menstrual cycles, reduce male hormone levels, and help to clear acne. However, the birth control pill does not cure PCOS. The menstrual cycle will become abnormal again if the pill is stopped.
Women may also think about taking a pill that only has progesterone, like Provera, to regulate the menstrual cycle and prevent endometrial problems. But progesterone alone does not help reduce acne and hair growth.
The drug metformin, also called glucophage, which is used to treat type 2 diabetes, also helps with PCOS symptoms. Metformin affects the way insulin regulates glucose and decreases the testosterone production. Abnormal hair growth will slow down and ovulation may return after a few months of use. These medications will not cause a person to become diabetic.
If a woman is not trying to get pregnant, there are some other medicines that may reduce hair growth. Other non-medical treatments such as electrolysis or laser hair removal are effective at getting rid of hair. A woman with PCOS can also take hormonal treatment to keep new hair from growing.
A surgery called ovarian drilling is available to induce ovulation. The doctor makes a very small incision above or below the navel, and inserts a small instrument that acts like a telescope into the abdomen. This is called laparoscopy. The doctor then punctures the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But these effects may only last a few months. This treatment doesn’t help with increased hair growth and loss of scalp hair.
Maintaining a healthy weight is another way women can manage PCOS. Since obesity is common with PCOS, a healthy diet and physical activity help maintain a healthy weight, which will help the body lower glucose levels, use insulin more efficiently, and may help restore a normal period. Even a loss of 10% of her body weight can help make a woman’s cycle more regular.
Note: There will be a public forum entitled ‘Overcoming Infertility: Treatment Options’, which will be presented by Dr Mahes Sittampalan on September 25, 2005 from 2-5pm at the MS Garden Hotel, Kuantan, Pahang. Admission is free and it will feature an exhibition, specialists’ consultation, semen analysis and an IVF lab tour. For more information, contact Matron Ang at 09-566 6403/Viji at 012-277 3391.
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