Polycystic Ovarian Disease (PCOD)
(also called PCOS)
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Patients suffering from polycystic ovarian disease (PCOD ) have multiple
small cysts in their ovaries ( the word poly means many). These cysts occur when
the regular changes of a normal menstrual cycle are disrupted. The ovary is
enlarged; and produces excessive amounts of androgen and estrogenic hormones.
This excess, along with the absence of ovulation, may cause infertility. Other
names for PCOD are polycystic ovarian syndrome (PCOS) or the Stein-Leventhal
PCOD (also called PCOS) can be easy to diagnose in some patients. The typical medical history is
that of irregular menstrual cycles, which are unpredictable and can be very
heavy ; and the need to take hormonal tablets (progestins) to induce a period.
Patients suffering from PCOD are often obese and may have hirsutism , (excessive
facial and body hair) as a result of the high androgen levels. However, remember
that not all patients with PCOD will have all or any of these symptoms.
This diagnosis can be confirmed by vaginal ultrasound, which shows that both
the ovaries are enlarged; the bright central stroma is increased ; and there are
multiple small cysts in the ovaries. These cysts are usually arranged in the
form of a necklace along the periphery of the ovary. Typically, blood levels of
hormones reveal elevated levels of androgens ( a high dehydroepiandrosterone
sulphate ( DHEA-S) level) ; a high LH level; and a normal FSH level.
Fig 1. A schematic, comparing a polycystic ovary with a
We don't really understand what causes PCOD (also called PCOS). However, we do know that the
characteristic polycystic ovary emerges when a state of anovulation persists for
a length of time. Patients with PCO have persistently elevated levels of
androgens and estrogens, which set up a vicious cycle. Obesity can aggravate
PCOD because fatty tissues are hormonally active and they produce estrogen which
disrupts ovulation . Overactive adrenal glands can also produce excess
androgens, and these may also contribute to PCOD.
Fig 2. The self-perpetuating vicious cycle of elevated
levels of androgens and estrogens in PCOD
Treatment of PCOD for the infertile patient will usually focus on inducing
ovulation to help them conceive.
Weight loss: For many patients with PCOD, weight loss is an effective
treatment - but of course, this is easier said than done! Look for a permanent
weight loss plan - and referral to a dietitian or a weight control clinic may be
helpful. Crash diets are usually not effective.
Increasing physical activity is an important step in losing weight. Aerobic
activities such as walking, jogging or swimming are advised. Try to find a
partner to do this with, so that you can help each other to keep going.
Ovulation Induction: The drug of first choice is clomiphene; this may
be combined with low-doses of dexamethasone, a steroid which suppresses androgen
production from the adrenal glands. Just taking clomiphene is not enough , and
you need to be monitored ( usually with ultrasound scans) to determine if the
clomiphene is helping you to ovulate or not. The doctor may have to
progressively increase the dose till he finds the right does for you. If
clomiphene does not work, HMG can be used. Some doctors prefer to use pure FSH
for inducing ovulation in PCOD patients because they have abnormally high levels
of LH. Ovulation induction can often be difficult in patients with PCOD , since
there is the risk that the patient may over-respond to the drugs, and produce
too many follicles, which is why the risk of ovarian hyperstimulation syndrome (
OHSS) and multiple pregnancy is often increased in patients with PCOD. The
doctor has to find just the right dose of HMG ( called the threshold value ) in
order to induce maturation and release of a single , or only a few follicles ,
and this can sometimes be very tricky. Difficult patients may also need a
combination of a GnRH analog (to stop the abnormal release of FSH and LH from
the pituitary) and HMG to induce ovulation successfully. Doctors have now
learned that many patients with PCOD also have insulin resistance – a
condition similar to that found in diabetics, in that they have raised levels of
insulin in their blood ( hyperinsulinemia) , and their response to insulin is
blunted. This is why some patients with PCOD who do not respond to clomiphene
are treated with antidiabetic drugs, such as metformin and troglitazone. Studies
have shown that these drugs can help to improve their fertility by reversing
their endocrine abnormality and thus improving their ovulatory response.
Surgery: A recent treatment option uses laparoscopy to treat patients
with PCOD. During operative laparoscopy, a laser or cautery is used to drill
multiple holes through the thickened ovarian capsule. This procedure is called
laparoscopic ovarian cauterisation or ovarian drilling or LEOS ( laparoscopic
electrocauterisation of ovarian stroma) . Destroying the abnormal ovarian tissue
helps to restore normal ovarian function and helps to induce ovulation. For
young patients with PCO ovaries on ultrasound, if clomiphene fails to achieve a
pregnancy in 4 months time, we usually advise laparoscopic surgery as the next
treatment option, This is because LEOS helps us to correct the underlying
problem; and about 80% of patients will have regular cycles after undergoing
this surgery, of which 50% will conceive in a year’s time, without having to
take further medication or treatment. Having regular cycles without having to
take medicines each month can be very reassuring to these patients ! The risk of
this surgery is that it can induce adhesion formation, if not performed
In the past, doctors used to perform ovarian surgery called wedge resection
to help patients with PCOD to ovulate. The removal of the abnormal ovarian
tissue in the wedge breaks the vicious cycle of PCOD, helping ovulation to occur
. While wedge resection used to be a popular treatment option, the risk of
inducing adhesions around the ovary as a result of this surgery has led to the
operation being used as a last resort.
For patients who do not respond to the above measures, intrauterine
insemination is the next step. Some difficult patients with PCO may also need
IVF in order to get pregnant. While PCO patients usually grow many eggs, quite a
few of these may be immature, so that fertilization rates may be lower than
average. Also, because of the PCOD, the risk of ovarian hyperstimulation
syndrome is increased in these patients.
The good news is that with the currently available treatment options,
successful treatment of the infertility is usually possible in the majority of
patients with PCOD.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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