Pregnancy delays and gynaecological issues are often the result of ovulation problems. In order to understand ovulation issues it is important to first understand how normal ovulation works. Ovulation is defined as the production of an egg on a regular, or cyclical, basis. The regular production of an egg is controlled by a number of factors, and is what ultimately allows a pregnancy to occur.
What is PCOS?
Simply explained PCOS is a disorganisation of ovarian function. A number of influences, both from inside and outside the ovary, disrupt the normal regulation of egg growth and release. A messenger hormone from the pituitary gland to the ovary normally regulates this process. However with PCOS this hormone release is not balanced and is often insufficient to maintain egg growth in a cycle.
Because the most common problem associated with PCOS is disordered ovarian function and poor ovulation it is very common for women who have PCOS to have difficulty becoming pregnant.
What causes PCOS?
Luteinising Hormone (LH) is the messenger hormone which triggers release of the egg - as many as 70-80% of women with PCOS may have high LH levels. Premature egg release is therefore possible, resulting in eggs that are prematurely aged. The higher levels LH may also alter the lining of the follicles where the eggs are growing contributing to pregnancy delay and infertility.
Many women with PCOS also have increased levels of male-type steroid hormones. These are produced mainly because the ovaries are acting in an abnormal way, but they are also produced in the fat tissue of the body. Many women with PCOS (~50%) also suffer from obesity and the excessive fat tissue contributes to the abnormally high levels of male hormone. These male hormones are in part responsible for some of the symptoms of PCOS including acne and abnormal hair growth.
PCOS and Ovulation
Each month in a normal menstrual cycle a large number of egg cysts begin their development as follicles. Normally only one of these follicles will be selected each month to develop and release a mature egg. However, in women with PCOS, the hormone communications are disorganised and this process of appropriate egg selection does not occur. Instead there may be many small, developing follicles within the polycystic ovary that will only rarely develop into a large follicle capable of releasing a mature egg.
This disorganised egg development, and fluctuating levels of male and female hormones, means that women with PCOS often have irregular or light periods. It is not a true period, which would normally follow after the orderly release of an egg.
What are the symptoms of PCOS?
If a woman identifies with any two of the following criteria (called the Rotterdam criteria) a diagnosis of PCOS may be made:
- Evidence of ovulation problems (observed as menstrual dysfunction)
- Evidence of male hormone excess (including acne and/or excessive hair growth)
- Ultrasound evidence of polycystic ovaries
Ovulation problems/ Irregular periods
Due to abnormal hormone production women with PCOS can have a variety of issues in relation to their periods and ovulation.
Women with PCOS often have absent, light or infrequent periods. This is because with PCOS the ovary does not reliably produce an egg so female hormone levels that the ovary produces are often low. Therefore the uterus does not receive enough messages to thicken its lining or trigger a period so bleeding does not occur.
Obesity can be a further contributing factor because fat tissue can produce both male and female hormones. Very obese women can in fact produce very large quantities of female hormone (mainly oestrogen) that have an effect on the ovary similar to taking the oral contraceptive pill. Excessively overweight women are more likely to have irregular periods and experience fertility issues.
Many women with PCOS are also obese (~50%). Unfortunately obesity can become self-perpetuating because the abnormal hormone levels being produced by the ovary can actually predispose you to obesity. Fat produces female hormone, which in turn can increases the level of disorganisation in the body’s environment, which can lead to further obesity.
That said some women whose ovaries function in a PCOS way can also be quite thin.
Acne and Abnormal Hair Growth (Hirsutism)
In women with PCOS Increased levels of male hormone are produced by the ovary and, to a lesser extent, by excess body fat. These raised male hormones may trigger acne outbreaks. Because different women will have different sensitivities to these hormonal changes there is no correlation between blood hormone levels and the severity of skin changes.
Women also vary in their ability to convert the male hormone into more active hormone which can in turn affect the skin and hair follicles of the skin. As a result of this some women will develop excessive hair growth, called hirsutism. This occurs particularly on the upper lip, chest, stomach, legs and arms. This may also affect the face were coarse hair growth can replace normal fine hairs.
PCOS and diabetes
There is a link between PCOS and insulin resistance. Insulin is the hormone responsible for helping sugar metabolise into energy. For some women with PCOS this means they will have trouble handling a sugar load. High levels of glucose will occur in the bloodstream because the body is not effectively utilising the insulin. When this happens the condition is called diabetes. It has been suggested that some women with PCOS should be tested for early stages of diabetes. Women with PCOS are 3-7 times more likely to develop diabetes later in life.
Women with PCOS are also more likely to develop diabetes while pregnant; this is known as gestational diabetes. It is recommended that diabetes testing should be done on women with PCOS at about 26 – 30 weeks of pregnancy.
How can we diagnose or test for PCOS?
Blood tests can measure the levels of FSH, LH and circulating male hormones. In women with PCOS the LH levels are often higher than the FSH levels (normally FSH levels are higher than LH).
The circulating male hormones can include both testosterone and free testosterone (which is not bound to the protein that carries it around in the bloodstream). Dehydroepiandrosterone sulphate (DHEAS) is another male hormone precursor, and is the most commonly elevated male hormone in women with PCOS. However, it should be noted that symptoms of male hormone excess are more important than measuring blood levels alone.
Ultrasound scans (USS)
An ultrasound scan (often transvaginal) is typically performed to aid in the diagnosis of PCOS. Polycystic ovaries often contain many small follicles (12 or more) and the ovaries ovaries may also seem increased in size.
Could a common gynaecological condition, such as PCOS, be the cause of your pregnancy delay? Use our self-assessment tool below to learn more:
How do we treat PCOS?
There are a number of treatment options for women with PCOS, and these will depend on the individual circumstances. Your fertility specialist will discuss all available options with you including:
- A change of diet and increased exercise alone could have a significant impact. Weight loss helps to balance hormones and restore regular periods in obese women
- Insulin sensitisers, such as Metformin, reduce the impact of insulin resistance and can also assist in weight loss
- Ovulation inducing drugs such as Clomiphene (Serophene or Clomid) can stimulate the ovaries
- Injectable drugs (FSH) can also be used, but these require specialist facilities and close monitoring of the response, to avoid severe side effects and multiple pregnancies
- Assisted reproduction technologies, including IVF
The success rates with these treatments are very high. Ovulation defects are the most successfully treated area of infertility.
First appointment overview and costs
All Queensland Fertility Group doctors are expert gynaecologists specialising in fertility, and can assist with diagnosing PCOS and identifying the best course of treatment - whether you're looking to get pregnant or not.
The approximate out-of-pocket cost for an initial consultation starts around $90. If you are specifically seeking help to fall pregnant, we recommended your partner attends this appointment as well. The approximate out-of-pocket cost for a first appointment for both you and your partner varies from around $100-$150.
Typically during a first appointment your specialist will assess your medical history, and will most likely recommend investigations such as blood tests (many of these are bulk billed) and an ultrasound scan. The results of these will help you and your Fertility Specialist determine the next steps for your individual circumstances. You should feel comfortable in your initial appointment to mention any concerns you may have, and ask any questions.
Download our Polycystic Ovarian Syndrome (PCOS) Booklet
For more information about polycystic ovarian syndrome, visit our Patient Information Booklets page. This booklet explains the symptoms, treatments and ways to cope with the stress of infertility. Download our Polycystic Ovarian Syndrome Booklet...
If you know or suspect you have PCOS and are trying to conceive, a Queensland Fertility Group Fertility Specialist can help. All of our doctors are expert gynaecologists and/or obstetricians who have undertaken additional training and specialise in fertility.
If you would like more information, to have your questions answered in a free phone consultation with a fertility nurse, or to book an appointment, please call 1800 111 483 or email us.
*Content courtesy of Dr David Molloy, Medical Director Queensland Fertility Group. For more information on PCOS, visit:www.gynaecologymolloy.com/polycystic-ovarian-syndrome.html