Polycystic Ovary Syndrome: Issues with Pregnancy, Infertility

Polycystic ovary syndrome (abbreviated as PCOS) occurs in 5-10% of women. This disease is one of the most common endocrine gland disorders in women of childbearing age (approximately between the ages of 15 - 40). 

PolyCystic Ovary Syndrome - PCOS is not clearly defined. 

At present, this disease is still receiving detailed attention because its cause and subsequent treatment are not clearly understood. 

We live in a hectic time where high pressure is put on us and under the influence of stress and work pressure, this is also reflected in our health. In recent years, the number of infertility has increased in both women and men.

And it is polycystic ovary syndrome that is one of the most common causes of infertility.  

The word polycystic is a compound word:
Poly = many
and
cystic = a cavity filled with liquid or mushy contents.

A large number of small cysts form in the ovaries. Cysts are actually follicles filled with fluid in which immature eggs are found.

However, the eggs in them never mature enough to trigger ovulation. 

The ovary is enlarged, usually up to the size of a hen's egg, and there are 10 or more cysts in the ovary, under the cortex, which are 2-8 mm in size. 

PCOS affects a woman's reproductive organs and ovaries, which produce the hormone estrogen and progesterone. These regulate the menstrual cycle. 

The ovaries also produce small amounts of androgens - male hormones. 

Polycystic ovary syndrome, PCOS or hyperandrogenic syndrome, is characterized by increased production of androgens than the normal value. 
This is associated with irregular menstrual cycles and anovulation.

Table: Normal hormone levels of a woman of reproductive age 

Due to the variety and large number of symptoms, which can be of gynecological origin, they also interfere with the activity of the glands of internal secretion, which is dealt with in endocrinology, but also in internal medicine. 

Treatment must be initiated according to the symptoms, which is individual for each woman. 

The basis of treatment should be to resolve the difficulties suffered by women with PCOS and then to get rid of the symptoms of increased androgen production for a successful and successful pregnancy and subsequent childbirth. 

PCOS and pregnancy

PCOS disrupts the menstrual cycle and thus makes it difficult to get pregnant. 

70 - 80% of women have a fertility issue. 

With fertility treatment, by improving ovulation, women can become pregnant. PCOS increases risks and complications during pregnancy. 

There is a risk of miscarriage, twice the likelihood of premature birth, high blood pressure and gestational diabetes. 

Weight loss, a healthy diet and low sugar intake increases the chances of a healthy pregnancy. 

History records the first description of PCOS in 1935 by a pair of gynecologists, Irving F. Stein and Michael L. Leventhal, who also described the link between the symptoms of the disease. 

To confirm the disease, historically a surgical incision was made into the abdominal cavity followed by a biopsy - taking a tissue sample from the ovary. 

In the 1930s, PCOS used to be termed Stein-Leventhal syndrome. 

Currently, the name polycystic ovary syndrome, also called hyperandrogenic syndrome, is used. 

PCOS is a complex of diseases. The cause of the development of PCOS is not clearly defined. 

Doctors still can not say what causes its occurrence.

Polycystic ovary syndrome affects female hormone levels. It involves a wide spectrum of female patients. PCOS is a disease with symptoms that affect the ovaries and ovulation. 

The main cause is the disparity between female and male hormones. High levels of male hormones prevent the ovaries from producing hormones and subsequently producing mature eggs. 

By overproducing male hormones, menstruation is disrupted and comes at less frequent intervals. 

It skips menstruation and with that, getting pregnant becomes more difficult. 

Many genes contribute to the disease - not just one. Not only genetic influences but also environmental influences, where diet, obesity and increased intake of saturated fats play a big role. 

In PCO syndrome, 40-60% of women are obese. 

Obesityis more common than in healthy women, and true obesity exacerbates all manifestations. Obesity is associated with insulin resistance, which itself is a trigger of PCOS. 

Insulin resistance occurs in up to 70% of women with PCOS. 

Insulin is a hormone made by the islets of Langerhans in the pancreas, which produces it to help the body convert sugar from food into energy. If the body fails to use insulin properly, its need increases. By secreting more insulin, more male hormones are produced in the female body. 

Obesity is a major cause of insulin resistance and together these increase the risk of developing type 2 diabetes. 

Genes, insulin resistance and also inflammation are associated with excessive androgen production. 

The ovary houses the eggs and after its release, ovulation follows, which is controlled by the hormones FSH - follicle-stimulating hormone and LH - luteinizing hormone. FSH encourages the ovary to form a follicle - the sac that contains the egg and LH encourages the ovary to release the egg. 

Women with PCOS often have increased levels of inflammation in the body.

Being overweight also contributes to inflammation. 

Taking valproates, anabolic steroids can cause PCOS. 

The first symptoms begin to appear in some women already at the time of the first menstruation, in the adolescent period. 

Some women don't even know they have PCOS and only find out when they put on a lot of weight or have trouble getting pregnant. 

When is it time to see a doctor? 

• If you have a problem with your menstrual cycle, miss your periods and are not pregnant
• Have you noticed hair growth on your face or body that you didn't have before
• You are trying to conceive and have been trying to conceive for more than 12 months
• You have symptoms of diabetes such as thirst or hunger, weight loss, blurred vision

The main symptoms are:

• Cysts in the ovaries, polycystic ovaries  
• Hyperandrogenism -high levels of male hormones
  Higher androgen levels which affects your fertility. 
• Menstrual cycle disorders to sterility

The most common symptoms of menstrual cycle disorders are: 

• Oligomenorrhea is most common in PCOS in up to 80% of women. Infrequent menstruation, prolongation of the menstrual cycle at an interval of more than 35 days, during the whole year menstruation occurs only 4 -9 times.
• Hypermenorrhea - heavy bleeding. Due to irregular menstruation, the lining of the uterus is not cleaned regularly, and its lining accumulates for a long time, resulting in heavy bleeding after the onset of menstruation.
• Amenorrhea - the absence of menstrual bleeding. 
• Oligoovulation- irregular ovulation. 
• Anovulation - the absence of ovulation, i.e. sterility. 

Sterility is present in 90-95% in PCOS.

Skin symptoms:

• Hirsutismin up to 70% of cases. Excessive pubic hair, the growth of pubic hair in places typical for men. On the face and body - back, abdomen and chest.
• Acne- due to hormonal changes, there is excessive sebum production, the skin is more oily and this causes rashes on the face, chest and upper back.
• Seborrhoea - red, itchy rashes mainly on the scalp, face and other parts of the body.
• Androgenetic alopecia - the hair on the head falls out and its quality is thinner.
• Darkening of the skin, dark patches on the skin that may form in body folds, such as the neck, groin and under the breasts.  

Other symptoms: 

• Morphological changes on the ovaries
• Weight gain
• Obesity
• Headaches due to hormonal changes.
• Galactorrhoea - milk production in the mammary glands of women who do not lactate. 
• Sleep apnea - repeated pauses in breathing during the night that interrupt sleep.  It is more common in overweight women - especially if they also have PCOS. The risk of sleep apnea is 5 to 10 times higher in obese women with PCOS.
• Depression- Hormonal changes and unwanted symptoms such as pubic hair growth can negatively affect your emotions. Hormonal imbalances affect a woman's health in a variety of ways.
• Insulin resistance - reduced effectiveness of insulin. It is very often an associated disease for PCOS and together they play a role in the development of type 2 diabetes mellitus and to impaired glucose tolerance. The endocrine system is disrupted, by excessive androgen secretion, and most women also have abnormal insulin activity.
• Sleep disorders

The long-term risk is:

• glucose tolerance disorder
• occurrence of type 2 diabetes 
• Ischaemic heart disease  - with PCOS the risk of developing it is twice as high. 
• Metabolic syndrome – a cluster of conditions that occur together, increasing your risk of heart disease. 
• Endometrial cancer. During menstruation, the lining of the uterus is secreted if it is not regular, the lining of the uterus is insufficiently cleansed, which makes it thicker and can increase the risk of endometrial cancer. 

The interplay of all the symptoms and manifestations is highly variable and can change over the years for each woman. 

Diagnosis of polycystic ovary syndrome is quite challenging because the symptoms can be very similar to those of other diseases, which must first be ruled out in order to reach a definitive diagnosis and treatment.

Diagnosis is made on the basis of history, symptoms, palpation, USG findings, determination of blood levels of hormones and tumor markers. 

The doctor will check your menstrual cycle based on your period record, enquiring if you have noticed symptoms such as acne, weight gain, hair growth on your face or body. 

Blood tests are done to check the level of male hormones in the woman's blood. Their normal value, or for evidence of high levels of androgen in the blood. 

Blood tests also check other hormones, cholesterol, insulin and triglyceride levels to assess the risk of related conditions such as heart disease and diabetes.  

Gynaecological examination, by examining the pelvis, various problems with the ovaries and reproductive organs of a woman can be detected. 

Ultrasound, a sonographic examination by which abnormal follicles and other diseases with the ovaries and uterus can be picked up. 

The ovaries in PCOS are enlarged, shiny, white. 

To determine the disease, in 2003, experts agreed on 3 symptoms by which the diagnosis of PCOS was decided: 

• Proving polycystic ovaries 
• Manifestations of hyperandrogenism or laboratory-proven hyperandrogenemia  
• Oligoovulation, anovulation

In 2006, according to experts, a new regulation was adopted in determining the diagnosis of PCOS, which is established on the basis of the presence of two or three symptoms: 

• Hyperandrogenism high androgen levels
• Ovarian dysfunction (chronic anovulation) irregular menstruation and cysts in the ovaries
• Exclusion of other causes that may have triggered this combination of symptoms 

The disease causing the hyperandrogenic state may be hyperprolactinemia, Cushing's syndrome, hypothyroidism, acromegaly, premature ovarian failure, obesity, ovarian tumors, or the effects of medications. 

Diagnosis can be confirmed by pelvic examinations, blood tests and ultrasound. 

Only on the basis of polycystic ovaries and their morphological change had to be abandoned. 

One symptom is not enough.

Whereas polycystic ovaries also occur in hypothyroidism or hyperprolactemia, but also with a regular menstrual cycle of a healthy woman and with normal androgen levels. 

Diagnosis of PCOS requires close cooperation of doctors gynecologist, internist, diabetologist, endocrinologist, but also cardiologist. 

Many women don't even know they have polycystic ovary syndrome because they haven't shown any significant symptoms of the disease that would register that something is wrong. 

The course of the disease is manifested by a wide scale of symptoms. It manifests itself differently in each patient and therefore treatment is approached individually. 

The absence or lack of ovulation alters the levels of the hormones estrogen, progesterone, FSH and LH. Estrogen and progesterone levels are lower and androgen levels higher than normal. 

As a result of increased production of male hormones, the menstrual cycle is disrupted. Menstruation does not come regularly, but with a delay, or even completely missed. This makes it difficult to get pregnant.  

If a woman with this diagnosis decides to become pregnant, fertility treatment is initiated to support and improve ovulation. When they do manage to become pregnant it is important to monitor the entire course of the pregnancy to avoid the risk of miscarriage or premature birth.

A healthy lifestyle, changing your diet, exercising, losing weight and lowering your blood sugar increase the chances of a healthy pregnancy.