Associate Professor Beverley Vollenhoven
BS (Hons) PhD FRANZCOG CREI
View A/Professor Vollenhoven’s profile here
The term “polycystic ovaries” does not mean there are a lot of cysts in the ovaries. What it refers to, is the number of follicles. Follicles are tiny cysts that have eggs in them, and we hope that all women of reproductive age have many of these follicles. Follicles can be seen on an internal or pelvic ultrasound.
Because the term “polycystic ovaries” implies that a woman has cysts in the ovaries, there is now a movement to have this renamed to “multi-follicular ovaries” reflecting the actual circumstance. When a woman has multi-follicular ovaries, the ovaries are slightly larger than normal ovaries and usually do not cause any pain or discomfort for the woman.
Figure 1. Comparison of normal ovary and polycystic or multi-follicular ovary. The dark spaces represent the follicles.
Multi-follicular ovaries are very common and can occur in about 20-40% of women in Australia depending on the definition. Most women who have multi-follicular ovaries have no other symptoms and are completely healthy and fertile.
There has also been a recent change to the definition of multi-follicular ovaries or polycystic ovaries. Until recently, to make a diagnosis you needed to have twelve follicles on one ovary. This has now changed to 25 follicles in each ovary or a combined total of 50 follicles. This definition change occurred in early 2015 and is being adopted throughout the medical community.
Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome or PCOS is actually a syndrome. It is a hormonal condition that can impact the physical health and emotional wellbeing of a woman.
PCOS has reproductive implications, metabolic and emotional effects.
The most common symptom of PCOS is irregular bleeding; some women will experience no menstrual period at all; however most will have a menstrual period, albeit irregular.
Other symptoms include acne, excess body or facial hair known as hirsutism where hair is present in non-female body parts like the upper lip, alopecia or loss of scalp hair, emotional distress and body image challenges as well as reduced fertility.
PCOS also has significant longer term complications that can be quite serious for some women. One of these is type 2 diabetes; diabetes that generally occurs as a women ages. Depending on weight; it can also lead to gestational diabetes that occurs during pregnancy.
There can also be a greater risk of heart disease and this can be related to the woman having higher cholesterol. In addition, when a woman is not having regular periods, the endometrium can overgrow and can develop into a hyperplasia and then an endometrial cancer.
A considerable number of women with PCOS also suffer sleep apnoea, regardless of their weight. An overwhelming number of women with PCOS are overweight and about 50% of these women are obese.
The psychological features of PCOS include increased anxiety and depression. Often if a woman is overweight, there will generally be concerns with low self-esteem and poor body image, and sadly these can develop into eating disorders such as bulimia. It should be highlighted that many people with PCOS can benefit greatly from psychological support and it is encouraged for PCOS sufferers to establish a support network that works for them.
The reproductive implications of PCOS include hyperandrogenism, this is characterised by excessive levels of androgens in the body and leads to acne as well as hirsutism, anovulation or the lack of ovulation and infertility.
It should be highlighted that 60% of women with PCOS are fertile and have a spontaneous pregnancy without problems.
There is no cure for PCOS, however, PCOS can be managed brilliantly well. A woman who is diagnosed with PCOS shouldn’t feel that she has a major condition that cannot be managed.
Management of PCOS is a partnership between the woman and her treating doctor. A healthy lifestyle is most important and will help reduce the risks of PCOS, particularly diabetes.
Due to the nature of weight issues with women diagnosed with PCOS, lifestyle is very important. If a woman with PCOS is very thin, she will still have an increased risk of developing diabetes. If a woman with PCOS is overweight; she will have a magnified risk of diabetes. Due to this, a healthy lifestyle is vitally important in management.
A good diet, maintaining regular exercise and maintaining a BMI as close as possible to the healthy weight range is essential. Assistance from a dietitian may be required as they are very good at managing diet for women with a PCOS diagnosis.
PCOS & Fertility Treatments
Treatments relating to fertility include very important lifestyle changes. Research has shown that women who are overweight or obese have a lower chance conceiving, regardless of if they are undergoing fertility treatment or trying naturally.
If an overweight woman becomes pregnant, there is also a greater risk of miscarriage so lifestyle changes are really very important to the health of mother and baby.
Medical management of PCOS includes clomiphene citrate or the oral drug ‘clomid’ and many women will ovulate and subsequently have a pregnancy. Other options include the injection of hormones such as gonadatrophins.
There will be a group of women who don’t become pregnant with these treatments and will require IVF. Particularly, if the couple have severe male factor infertility or the woman has PCOS as well as a problem with her fallopian tubes. In these cases, IVF is going to be the primary choice for becoming pregnant for these couples.
PCOS is a condition that you can live with, however it’s really important to get the right diagnosis. Many women in the past have received an incorrect diagnoses of Polycystic Ovarian Syndrome and just had polycystic looking ovaries. If you do have PCOS, there are long term health risks and it’s important to actually look at preventative steps to reduce the risks and although a healthy lifestyle has been mentioned many times, it really is such an important factor for these women.
Regulation of Menstrual Cycle
For women who are not currently looking to get pregnant, or who have had children, regulation of their cycle is important. This will ensure they prevent any overgrowth of the endometrium that can lead to the development of endometrial cancer.
There are three options for protecting the lining of the uterus:
Oral Contraceptive Pill – women who are on the pill regardless of if they have a regular period or not, just need to be on pill for 12 months and the risk of endometrial cancer reduces by 50%. The oral contraceptive pill can also assist in the regulation of hormones which can alleviate the symptoms of acne and facial hair.
Mirena IUD – a contraceptive device that causes the lining in uterus (endometrium) to become very thin and inactive and therefore prevents any overgrowth in the lining.
Some women with PCOS will experience severe hyperplasia; a very severe overgrowth in the endometrial lining that left untreated, can lead to endometrial cancer. These women can also be treated with a Mirena IUD for six months, the Mirena IUD is then removed, and for most women the precancerous changes will have disappeared.
The other option for regulating cycles or preventing an overgrowth in the lining is to take regular progestogen. These drugs will cause a regular shedding of the lining, however are not a contraceptive.
There are many resources available for women with PCOS and specifically the Patient Handbook developed by the Polycystic Ovarian Syndrome Association of Australia which can be accessed at managingpcos.org.au. In addition, Associate Professor Beverley Vollenhoven will be presenting a webinar on PCOS Tuesday 23rd February 2016. You can register for the webinar here.
Associate Professor Beverley Vollenhoven is a Monash IVF Clinician specialising in all aspects of Reproductive Endocrinology and Infertility. She holds a Certificate of Reproductive Endocrinology, the highest recognised qualification for Fertility Specialists in Australia. A/Prof Vollenhoven holds board appointments with the Fertility Society of Australia and the Advisory Committee for Prescriptive Medicines as well as appointments at Monash University, Monash Health, and is a senior examiner for the specialist and subspecialist exams and the Australian Medical Council.
If you would like to book an appointment with A/Professor Vollenhoven, please complete our online booking form.