Dr. Kemi Ailoje

Infertility is a major challenge affecting families across the globe, some of the causes are however treatable if only enough information about the challenges is addressed by specialists. There is the need therefore for the increased public education, awareness and advice on these issues. These and other topics will be looked at and distilled in this column.

The first in line of the many topics will be Polycystic Ovarian Syndrome (PCOS) which affects 5-10 per cent reproductive age women and therefore it is a common endocrine disorder.

A previous report from different countries shows the diversity in the incidence of PCOS with great concern which may make PCOS epidemic, however the statistics for PCOS in Nigeria is very scanty. Therefore, it is important to evaluate current PCOS status in the country and understand PCOS-related risk in order to effectively prevent and treat women especially teenagers. It is worthy of note that despite the high incidence of PCOS most Nigerian women especially teenagers do not know much about it.
PCOS is not a new condition. Italian physician Antonio Vallisneri first described its symptoms in 1721.

What is Polycystic Ovary Syndrome?
Polycystic Ovary Syndrome (PCOS) is a condition that affects a woman’s hormone levels. It is a hormone imbalance problem, which affects women during their childbearing years (ages 15 to 44). Many women have PCOS but don’t know it. In one study, up to 70 per cent of women with PCOS hadn’t been diagnosed ever before study was carried out.
PCOS is common, affecting as many as 1 out of 15 women. Often the symptoms begin in the teen years. Treatment can help control the symptoms and prevent long-term complications such as infertility, heart diseases and diabetes.
Most women with PCOS grow many small cysts on their ovaries. That is why it is called polycystic ovary syndrome. The cysts are not harmful but lead to hormone imbalance. This hormone imbalance causes them to skip menstrual periods and makes it harder for them to get pregnant.

PCOS affects a woman’s ovaries which are the reproductive organs that produce estrogen and progesterone hormones which regulates the menstrual cycle. The ovaries also produce a small amount of male hormones called androgens. The sex hormones may get out of balance. Normally, the ovaries make a tiny amount of male sex hormones (androgens) but in PCOS, they start making slightly more androgens. This may cause the body to stop ovulating, get acne, and grow extra facial or body hair and in some cases baldness.

The body may have a problem using insulin, called insulin resistance. When the body does not utilise insulin well, blood sugar levels rises. Over time, this increases the chance of getting diabetes and heart disease.
Birth control pills and diabetes drugs can help fix the hormone imbalance and improve symptoms.

The ovaries release eggs to be fertilised by a man’s sperm. The release of an egg each month is called ovulation.
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) control ovulation. FSH stimulates the ovary to produce a follicle (a sac that contains an egg) and then LH triggers the ovary to release a mature egg.

In PCOS, many small, fluid-filled sacs grow inside the ovaries. The word “polycystic” means “many cysts.”
These sacs are actually follicles, each one containing an immature egg. The eggs never mature enough to trigger ovulation.

The lack of ovulation alters levels of estrogen, progesterone, FSH, and LH. Estrogen and progesterone levels are lower than usual, while androgen levels are higher than usual.

Extra male hormones disrupt the menstrual cycle, so women with PCOS get fewer periods than usual.
In other words, PCOS is a syndrome, or group of symptoms that affects the ovaries and ovulation with the main features being:
• high levels of male hormones
• multiple cysts in the ovaries
• irregular or skipped periods

What happens in PCOS regarding hormones?
Hormones are chemical messengers that trigger many different processes, including growth and energy production. Often, the job of one hormone is to signal the release of another hormone.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change triggers another, which changes another.

What are the symptoms?
Symptoms tend to be mild at first. You may have only a few symptoms or a lot of them. The most common symptoms are:
• Acne
• Weight gain and trouble losing weight.
• Extra hair on the face and body. Often women get thicker and darker facial hair and more hair on the
chest, belly, and back.
• Thinning hair on the scalp.
• Irregular periods. Often women with PCOS have fewer than nine periods a year. Some women have no periods.

Others have very heavy bleeding.
• Many women who have PCOS have trouble getting pregnant (infertility).

• Depression.

What causes it?
The exact cause of PCOS is unknown. It is believed that high levels of male hormones (androgens) prevent the ovaries from producing hormones and making eggs normally.

Genes, insulin resistance, and inflammation have all been linked to excess androgen production
Genes: It is likely that many genes not just one contribute to the condition.

Insulin resistance: Up to 70 per cent of women with PCOS have insulin resistance, meaning that their cells can’t use insulin (the hormone the pancreas produces to help the body use sugar from foods for energy), properly. This results in the increased body’s demand for insulin. The pancreas makes more insulin to compensate. Extra insulin triggers the ovaries to produce more male hormones.

Obesity: A major cause of insulin resistance. Both obesity and insulin resistance can increase your risk for type 2 diabetes.

Inflammation: Women with PCOS often have increased levels of inflammation in their body. Being overweight can also contribute to inflammation. Studies have linked excess inflammation to higher androgen levels.

What are the effects of PCOS on the body?
Having higher-than-normal androgen levels can affect fertility and other aspects of health.
Infertility: To get pregnant, you have to ovulate. Women who don’t ovulate regularly don’t release as many eggs to be fertilised. PCOS is one of the leading causes of infertility in women.

Metabolic syndrome: Up to 80 per cent of women with PCOS are overweight or obese. Both obesity and PCOS increase your risk for high blood sugar, high blood pressure, low HDL (“good”) cholesterol, and high LDL (“bad”) cholesterol. Together, these factors are called metabolic syndrome, and they increase the risk for heart disease, diabetes, and stroke.

Sleep apnea: This condition causes repeated pauses in breathing during the night, which interrupt sleep. It is more common in women who are overweight especially if they also have PCOS. The risk for sleep apnea is 5 to 10 times higher in obese women with PCOS than in those without.

Endometrial cancer: During ovulation, the uterine lining sheds. If you don’t ovulate every month, the lining can build up. A thickened uterine lining can increase your risk for endometrial cancer.

Depression: Both hormonal changes and symptoms like unwanted hair growth can negatively affect emotions. Many people with PCOS end up experiencing depression and anxiety.

How is PCOS diagnosed?
PCOS in women is typically diagnosed when a doctor notices at least two of these three major symptoms:
• High androgen levels
• Irregular menstrual cycles
• Cysts in the ovaries
Your doctor should also ask whether you have had symptoms like acne, face and body hair growth, baldness and weight gain.

Physical examination needs to be done to rule out male pattern hair distribution and PCOS-like features.
A transvaginal ultrasound scan can be done to check for abnormal follicles and other problems with your ovaries and uterus.

Blood tests check for higher-than-normal levels of male hormones, check for cholesterol, insulin, and triglyceride levels to evaluate the risk for related conditions like heart disease and diabetes.

Pregnancy and PCOS
PCOS interrupts the normal menstrual cycle and makes it harder to get pregnant. Between 70 and 80 per cent of women with PCOS have fertility problems

This condition can also increase the risk for pregnancy complications.
Women with PCOS are twice as likely as women without the condition to deliver their baby prematurely. They are also at greater risk for miscarriage, high blood pressure, and gestational diabetes

However, women with PCOS can get pregnant using fertility treatments that improve ovulation. Losing weight and lowering blood sugar levels can improve the odds of having a healthy pregnancy.

Management of PCOS
Treatment for PCOS usually starts with lifestyle changes like weight loss, diet, and exercise.
Losing just 5 to 10 per cent of your body weight can help regulate your menstrual cycle and improve PCOS symptoms. Weight loss can also improve cholesterol levels, lower insulin, and reduce heart disease and diabetes risks.

Any diet that helps you lose weight can help your condition. However, some diets may have advantages over others.
Studies comparing diets for PCOS have found that low-carbohydrate diets are effective for both weight loss and lowering insulin levels. A low glycemic index (low-GI) diet that gets most carbohydrates from fruits, vegetables, and whole grains helps regulate the menstrual cycle better than a regular weight loss diet.

A few studies have found that 30 minutes of moderate-intensity exercise at least three days a week can help women with PCOS lose weight. Losing weight with exercise also improves ovulation and insulin levels.

Exercise is even more beneficial when combined with a healthy diet. Diet plus exercise helps you lose more weight than either intervention alone, and it lowers your risks for diabetes and heart disease.

Common medical treatments
Birth control pills and other medicines can help regulate the menstrual cycle and treat PCOS symptoms like hair growth and acne.

Birth Control: Taking estrogen and progestin daily can restore a normal hormone balance, regulate ovulation, relieve symptoms like excess hair growth, and protect against endometrial cancer. These hormones come in a pill, patch, or vaginal ring.

Metformin: Metformin (Glucophage, Fortamet) is a drug used to treat type 2 diabetes. It also treats PCOS by improving insulin levels.

One study found that taking metformin while making changes to diet and exercise improves weight loss, lowers blood sugar, and restores a normal menstrual cycle better than changes to diet and exercise alone.

Clomiphene: Clomiphene (Clomid) is a fertility drug that can help women with PCOS get pregnant. However, it increases the risk for twins and other multiple births. The use must be monitored by a doctor.

Hair removal medicines: A few treatments can help get rid of unwanted hair or stop it from growing. Eflornithine (Vaniqa) cream is a prescription drug that slows hair growth. Laser hair removal and electrolysis can get rid of unwanted hair on your face and body.

Surgery: This can be an option to improve fertility if other treatments don’t work. Ovarian drilling is a procedure that makes tiny holes in the ovary with a laser or thin heated needle to restore normal ovulation.

When to seek specialist care:
• Missed periods and you are not pregnant after a pregnancy test done.

• You notice symptoms of PCOS, such as hair growth on your face and body.

• Unsuccessful attempt at trying to get pregnant despite unprotected regular sexual intercourse for more
than 12 months.

• You have symptoms of diabetes, such as excess thirst or hunger, blurred vision, or unexplained weight
loss.

• If you have PCOS, plan regular visits with your specialist.

• You will need regular tests to check for diabetes, high blood pressure, and other possible complications.
What women especially the young need to know about PCOS

• PCOS can disrupt a woman’s menstrual cycles and make it harder to get pregnant.

• High levels of male hormones also lead to unwanted symptoms like hair growth on the face and body.

• Lifestyle interventions are the first treatments specialists recommend for PCOS, and they often work well.

• Weight loss can treat PCOS symptoms and improve the odds of getting pregnant and having healthy babies.

• Diet and aerobic exercise are two effective ways to lose weight.

• Medicines are an option if lifestyle changes don’t work.

• Birth control pills and metformin can both restore normal menstrual cycles and relieve PCOS symptoms.