Obstetric & Gynaecology Malaysia


Polycystic ovary syndrome (PCOS) is a condition that causes irregular menstrual periods because monthly ovulation is not occurring and levels of androgens (male hormones) are elevated. The condition occurs in approximately 5 to 10 % of women. The elevated androgen levels can sometimes cause excessive facial hair growth, acne, and/or male-pattern scalp hair thinning. Most, but not all, women with PCOS are overweight or obese, and they are at higher-than-average risk of developing diabetes and obstructive sleep apnea.

Most women with PCOS are able to lead a normal life without significant complications.

The cause of PCOS is not completely understood. With regards to the reproductive system, it is believed that abnormal levels of the pituitary hormone luteinizing hormone (LH) and high levels of male hormones (androgens) interfere with normal function of the ovaries.

In women with PCOS, multiple small follicles accumulate in the ovary. None of these small follicles/cysts are capable of growing to a size that would trigger ovulation. As a result, the levels of estrogen, progesterone, LH, and FSH become imbalanced.

PCOS is associated with elevated levels of insulin in the blood, INSULIN RESISTANCE. Insulin is a hormone in the pancreas to regulate blood glucose levels to help the body use glucose for energy.

●If glucose levels do not respond to normal levels of insulin, the pancreas produces more insulin. 

●When increased levels of insulin are required to maintain normal glucose levels, a person is said to be insulin resistant.

●When the blood glucose levels are not well controlled with increased amounts of insulin, the person is said to have glucose intolerance or pre diabetes.

If ovulation does not occur, the lining of the uterus=endometrium does not shed and regrow as in a normal menstrual cycle. Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding. Irregular or absent menstrual periods can increase a woman's risk of endometrial overgrowth=ENDOMETRIAL HYPERPLASIA or even cause endometrial cancer.

Most women have normal cycles during puberty, which may become irregular if the woman becomes overweight, or they exceed their PERSONAL FAT THRESHOLD.

There is no single test for diagnosing PCOS. You may be diagnosed with PCOS based upon your symptoms, and a physical examination. Expert groups have determined that a woman must have two out of three of the following to be diagnosed with PCOS:

●Irregular menstrual periods caused by anovulation or irregular ovulation.

●Evidence of elevated androgen levels based upon signs eg excess hair growth, acne, or male-pattern balding.

●Polycystic ovaries seen on pelvic ultrasound.

In addition, congenital adrenal hyperplasia, androgen-secreting tumors, or hyperprolactinemia is excluded.

Blood tests are usually recommended to determine cause of irregular periods eg follicle-stimulating hormone (FSH),  luteinizing hormone (LH),  prolactin level, thyroid-stimulating hormone (TSH), FT4 and HbA1c should be done. If hirsuitism present, serum testosterone and dehydroepiandrosterone sulfate (DHEAS) can be taken.

Weight reduction through life styles changes is the first option for overweight women with PCOS. Women who lose significant amounts of weight can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes.

Metformin (Glucophage) is a medication that improves the effectiveness of insulin produced by the body. 

If a woman does not have regular menstrual cycles, the treatment option is is to take metformin for six months until menstrual cycles are regular with menses induction with 5 days progestin Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose slightly more weight when metformin is added.

Oral contraceptives (combined estrogen and progestin) are the used for regulating menstrual periods in women with PCOS. A word of caution for women who may gain weight with OCs. OCs protect the woman from endometrial hyperplasia by inducing a monthly menstrual period. OCs are also effective for treating hirsutism and acne by suppressing ovarian androgen production. A skin patch also available for contraception

If patient with PCOS have difficulty becoming pregnant after trial of Metformin for 6 months can proceed for ovulation induction with letrozole, and clomiphene. If tests determine that lack of ovulation is the cause of infertility, several treatment options are available. These treatments work best in women who are not obese.

The primary treatment for women who are unable to become pregnant and who have PCOS is weight reduction with lifestyle changes. Even a modest amount of weight loss may allow the woman to begin ovulating normally. In addition, weight reduction  can improve the effectiveness of other infertility treatments.

Clomiphene stimulates the ovaries to release one or more eggs. It triggers ovulation in approximately 80% of women with PCOS, and approximately 50 % of these women will become pregnant. Letrozole is a medication that is FDA approved for the treatment of breast cancer, but it is not approved for induction of ovulation. However, studies have shown that live birth rates are higher in obese women with PCOS when they are treated with letrozole rather than clomiphene. Many experts now recommend letrozole as the first choice of treatment for women with PCOS who want to conceive.

A few studies have shown that taking metformin in addition to clomiphene increases the rate of ovulation. Women who take metformin before pregnancy are usually advised to stop it once they become pregnant.