Polycystic Ovarian Syndrome in a patient is a challenging problem that takes a certain amount of finesse on the physician's part to handle, especially in women who are trying to conceive. We began the interview with a discussion of the pathophysiology of this syndrome. I told Sasha that in my opinion, PCOS is not a very good name for this syndrome, that it is more a description of what the ovaries look like, because in reality it is an OVARIAN dysfunction. The real problem is that the ovaries are not processing the hormones correctly. This causes them to not ovulate and produce the female hormones correctly, and instead the hormone precursors are shifted to production of the male hormone testosterone. We don't know exactly what it is in the ovary that causes this dysfunction.
I addressed the issue of correctly diagnosing PCOS, based on clinical findings. There is not a specific test that can be done. The physician must draw a clinical picture and look at a variety of factors in order to make this diagnosis. It is also a diagnosis of exclusion, which means that other causes such as other hormonal disorders, tumors and genetic abnormalities, must be investigated and ruled out first. The real name for this disorder is "idiopathic hyperandrogenism", which means increased male hormone.
There are many types of women who fall into this PCOS category. In the past, the classic PCOS was a woman that was obese, had facial hair, thinning hairline and irregular menstrual cycles. Now we are finding more and more atypical women presenting with this syndrome, including patients that may be slim, for instance, and it is only when you look at their ovaries with the ultrasound, or see how they respond to ovarian stimulation, or look at their blood tests, that you find they are PCOS. There are even a few that have regular menstrual cycles, and are found to be PCOS when they hyperstimulate from injectable fertility drugs.
What are some of the key indicators? Well, visually, a patient might present with increased facial hair, acne, perhaps be overweight but not necessarily. Blood tests can be done to show an increase in insulin, glucose or testosterone. We can also observe, through ultrasound, how the ovaries look in their pre-ovulatory state where there are lots of small follicles. Also, in most cases, the patient will have irregular or infrequent menstrual cycles. Hormone testing will show a normal TSH, Prolactin, Estradiol, FSH and LH. In some patients there will be the characteristic elevation in LH/FSH ratio. That is the LH level will be significantly higher than the FSH level. In some, testosterone levels will be elevated, but most will be at the high end of normal. In the patients that do not have regular menstrual cycles, the mid luteal phase progesterone level will be decreased, with a level less than 10, indicating that ovulation did not occur. Because there is such deviation in presentations, in most cases only one or two of the criteria need to be present to make the diagnosis.
What happens after the diagnosis and what about insulin resistance? I will go into further detail in my next blog post!