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PCOD: Polycystic Ovary Disease
Polycystic ovary syndrome (PCOS), now more
commonly known as polycystic ovary disease (PCOD), is thought to be
the most common cause of ovarian dysfunction in women of
reproductive age. As such, it is clearly a very important cause of
infertility and needs to be covered in some detail.
PCOD is a condition in which the ovaries are enlarged, with a
smooth but thicker than normal outer cover. Many small cysts cover
this surface, which are themselves harmless, but may cause
amenorrhoea or oligomenorrhea, resulting in
infertility.
Clinical features
The diagnostic criterion for PCOD is the finding
of polycystic ovaries on ultrasound scanning. This finding may be
accompanied by a wide spectrum of other signs and symptoms, the
main feature of which is hyperandrogenism. On investigation, the
serum LH (luteinizing hormone) is usually raised above 10 IU/l and
the serum testosterone may be elevated.
Signs and symptoms of PCOD:- Elevated LH levels (serum LH >10
IU/l).
- Low or normal FSH levels (if they are normal,
they are still probably below the threshold level required for
normal follicle development).
- Elevated LH/FSH ratio (>2:1 or 3:1).
- Elevated androgens/testosterone.
- Enlarged, multicystic ovaries.
- Multiple immature follicles (usually 2 mm to
8 mm).
- 10 follicles/ovary.
- Irregular menses and anovulation.
- Hirsutism and acne (resulting from an excess
of androgens).
- Obesity.
Although PCOD is associated with androgenic
symptoms such as hirsutism and obesity, they are not necessary for
the diagnosis. Seborrhoea is also a common feature.
PCOD and fertility
In the mildest forms of PCOD, the
affected woman may have no menstrual abnormality and may ovulate
normally, but often takes longer than normal to conceive and has a
higher chance of spontaneous miscarriage.
In moderate PCOD, there are menstrual irregularities
such as oligomenorrhoea or secondary amenorrhoea and failure of
ovulation.
The most severe form of PCOD is characterised by
obesity, hirsutism, amenorrhoea and consequential
infertility.
Management of PCOD
Management of PCOD depends on whether the woman
wishes to conceive or not. Sometimes, the return of ovulatory
cycles is brought about by simple measures such as weight
loss.
In women who do not wish to conceive, treatment may be symptomatic.
An oral contraceptive pill may be given to restore menstrual
regularity and oestrogens or anti-androgens such as cyproterone
acetate may be used in those with hirsutism or acne.
In women who wish to conceive, treatment is usually commenced with
clomiphene citrate (see Female Treatments) in doses of 50-110
mg/day for 5 days each month. This is effective in restoring
menstruation with ovulation in 70% of women, and 30% will conceive
within three months of treatment. However, pregnancy rates are low
and there is a high incidence of miscarriage.
If conception has not occurred after a six months trial of
clomiphene, a trial of gonadotropin therapy may be commenced,
sometimes in combination with a GnRH-analogue in order to block LH
secretion and thus lower the risk of miscarriage. This must be used
with great caution in patients with PCOD as these patients are very
susceptible to developing ovarian hyperstimulation syndrome, and
also because the response to the same dose of gonadotropin can
induce a quite different response in different cycles.
In order to reduce this variable dose-response as far as possible,
pure FSH preparations are preferred rather than impure extracts
such as hMG (see Module 2). In order to restore single ovulation
without causing ovarian hyperstimulation, it is important that the
gonadotropin dose can be titrated as precisely as possible and thus
only preparations of the highest purity should be
used.
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