Polycystic Ovary Syndrome Complications for Your Health
Besides fertility problems, PCOS complications include risk for developing insulin resistance and prediabetes/diabetes, abnormal cholesterol and triglyceride levels, heart disease, stroke, endometrial cancer (cancer of the inner lining of the uterus), obesity, and sleep apnea.
PCOS is a leading cause of fertility problems, but having a diagnosis of PCOS does not mean that you are infertile. PCOS is treatable and many women with PCOS do get pregnant naturally or with the help of fertility treatments.
Clomiphene (Clomid) is an oral fertility drug most often recommended, however, some recent research suggests that another oral drug letrozole (Femara) may be as effective. Other treatments may involve hormonal injections (gonadotropins) and procedures. Eating healthy, being active, getting good sleep, and keeping stress at bay is important. With PCOS, so much is interrelated and those are aspects that you can impact.
Ovarian hyperstimulation syndrome (OHSS) causes swelling of the ovaries, which leak fluid within the body. This condition occurs in women who receive fertility treatments that stimulate the ovaries to produce more eggs.
OHSS develops because of high levels of the pregnancy hormone HCG following these fertility treatments. PCOS and the use of fertility treatments increase the risk of OHSS.
Drugs used in fertility treatments cause the blood vessels surrounding the ovaries to leak fluid. This fluid causes the ovaries to swell. Sometimes this fluid moves into the belly and other areas, causing:
Swelling
Pain
Nausea
Vomiting
Increased thirst
In severe forms, the excess fluid can result in difficulty breathing and decreased urination.
OHSS used to occur in about 10% of women who receive in-vitro fertilization treatments, but today the number is less than 5%. When it occurs, OHSS is usually temporary and resolves within 1-2 weeks.
OHSS Symptoms
Symptoms of ovarian hyperstimulation syndrome often begin within a week after using injectable medications of HCG to stimulate ovulation, though sometimes it can take two weeks or longer for symptoms to appear. If you become pregnant during a treatment cycle, OHSS may worsen as your body begins producing its own HCG in response to the pregnancy.
The signs and symptoms of OHSS vary depending on the severity of the condition. Symptoms of mild to moderate OHSS include:
Abdominal discomfort/pain
Bloating
Slight weight gain
Nausea
Severe cases of OHSS occur rarely and can lead to hospitalization due to serious symptoms and complications including:
Excessive weight gain
Severe nausea and vomiting
Severe abdominal swelling
Difficulty breathing
Blood clots
Decreased urination
Kidney failure
Home Remedies
If you develop mild ovarian hyperstimulation syndrome, you'll probably be able to continue your day-to-day routine with these recommendations. However, always contact your doctor for any specific concerns or advice.
Try an over-the-counter painkiller such as acetaminophen (Tylenol) for abdominal discomfort, but avoid ibuprofen (Advil, Motrin IB) or naproxen sodium (Aleve) if you have recently had an embryo transfer, as these drugs can interfere with implantation of the embryo.
Maintain a light physical activity level, avoiding strenuous or high-impact activities.
Weigh yourself on the same scale and measure around your abdomen each day, reporting unusual increases to your doctor.
Avoid sexual intercourse, as it may be painful and can cause a cyst in your ovary to rupture.
Call your doctor if your signs and symptoms get worse.
Strategies to Prevent OHSS
Adjusting medication. Your doctor uses the lowest possible dose of gonadotropins to stimulate your ovaries and trigger ovulation.
Adding medication. Some medications seem to reduce the risk of OHSS without affecting the odds of pregnancy. These include low-dose aspirin; dopamine agonists such as cabergoline or quinagolide, and calcium infusions. Giving women who have polycystic ovary syndrome, the drug metformin during ovarian stimulation may also help prevent hyperstimulation.
Coasting. If your estrogen level is high or you have a large number of developed follicles, your doctor may have you stop injectable medications and wait a few days before giving HCG, which triggers ovulation. This is known as coasting.
Avoiding the use of an HCG trigger shot. Because OHSS often develops after an HCG trigger shot is given, alternatives to HCG for triggering have been developed using Gn-RH agonists, such as leuprolide (Lupron), as a way to prevent or limit OHSS.
Freezing embryos. If you're undergoing IVF, all the follicles (mature and immature) may be removed from your ovaries to reduce the chance of OHSS. Mature follicles are fertilized and frozen, and your ovaries are allowed to rest. You can resume the IVF process at a later date when your body is ready.
Preparing for a Doctor’s Appointment
Depending on how severe your ovarian hyperstimulation syndrome is, your first appointment may be with your primary care provider, your gynecologist or infertility specialist, or possibly with a treating doctor in the emergency room.
If you have time to prepare for your appointment, you should:
Write down any symptoms you're experiencing.
Make a list of any medications and vitamin supplements you take including doses and how often you take them.
Have a family member or close friend go with you if possible. You may become overwhelmed with information at your visit, and it can be difficult to remember everything. If you can’t bring a friend, bring a notebook to write important information.
Prepare a list of questions to ask your doctor including any concerns about symptoms you’ve been experiencing.
Some potential questions your doctor might ask you include:
When did your symptoms begin?
How severe are your symptoms?
Does anything make your symptoms better?
Does anything seem to make your symptoms worse?
Getting Diagnosed
Doctors diagnose OHSS with several tests:
Physical exam: Your doctor will check your weight and measure the size of your waist to look for signs of swelling. You will also want to discuss any abdominal pain you may have.
Ultrasound: This test looks for free fluid in the abdomen and the size of the ovaries. If you have OHSS, an ultrasound may show that your ovaries are bigger than normal, with large fluid-filled cysts where follicles developed. During treatment with fertility drugs, your doctor regularly evaluates your ovaries with a vaginal ultrasound.
Chest X-ray: This is used to look for fluid in the chest.
Blood test: A blood test will measure hormone levels for signs of OHSS. Certain blood tests also allow your doctor to check for abnormalities in your blood and whether your kidney function is being impaired because of OHSS.
Treatments
The treatment for OHSS varies depending on how severe the condition is. Treatment aims to manage symptoms and avoid complications.
For mild to moderate cases of OHSS, treatment usually involves:
Avoiding vigorous physical activity
Increasing fluids
Using acetaminophen to relieve symptoms
Weighing yourself daily
Monitoring yourself for any severe symptoms
Frequent physical exams and ultrasounds
Blood tests to monitor for dehydration, electrolyte imbalance, and other problems
Medications to prevent blood clots (anticoagulants)
Severe cases of OHSS often require hospitalization for monitoring and aggressive treatment, including IV fluids. Your doctor may give you a medication called cabergoline to lessen your symptoms. Sometimes, your doctor may also give you other medications, such as gonadotropin-releasing hormone (Gn-RH) antagonist or letrozole (Femara), to help suppress ovarian activity.
Other treatments of severe OHSS may include:
Adjusting your fertility medication dose
Freezing your embryos and delaying their embryo transfer until the ovaries return to normal
Undergoing paracentesis (a procedure to remove fluid from the belly)
Serious complications from ovarian hyperstimulation syndrome may require additional treatments, such as surgery for a ruptured ovarian cyst or intensive care for liver or lung complications. You may also need anticoagulant medications to decrease the risk of blood clots in your legs.
Sources: American Society for Reproductive Medicine, "Fact Sheet: Side-effect of injectable fertility drugs," revised 2012. Insler, V et al. "Prevention of ovarian hyperstimulation syndrome." UpToDate, reviewed February 2014. Cleveland Clinic. Mayo Clinic.
The PCOS Belly
Many women with PCOS have problems with bloating. Often this is aggravated by certain foods. The list of possible food culprits is varied, but it includes foods that contain a carbohydrate called raffinose. This carb doesn’t digest well for some people, leading to increased gas production. Foods in this group include asparagus, beans, broccoli, Brussels sprouts, cabbage, and cauliflower.
Knowing what foods trigger your PCOS bloating can help reduce your abdominal pain and discomfort.
Other foods that can cause bloating, include dairy products if you are lactose intolerant, certain whole grains, fruits, carbonated drinks, and products containing artificial sweeteners. The PCOS tracker can help you keep tabs on these troublesome foods. Simply writing down trigger foods can help reduce PCOS bloating.
PCOS has been strongly linked to sleep apnea. Sleep apnea is a sleep disorder characterized by brief episodes of stopped breathing during sleep. This disrupts sleep and impacts oxygen delivery to the body. Sleep apnea can lead to lower pain tolerance, high blood pressure, mood changes, heart disease, and increased weight. Signs of sleep apnea may also include
Excessive sleepiness during waking hours
Attention problems
Chronic snoring
Episodes of ceased breathing while asleep (witnessed by another person)
If you suspect a sleep problem, talk to your doctor. A sleep study is a test used to diagnose sleep apnea and other sleep disorders. During the test, the activity of your brain, heart, and lungs are monitored while you sleep. If sleep apnea or another sleep disorder is diagnosed, treatment (like CPAP for sleep apnea) can help. Treatment will help you get better sleep and better health.
Does PCOS Make You Tired?
PCOS and fatigue go hand-in-hand. In fact, fatigue is one of the leading symptoms reported among women with PCOS. Additional causes of fatigue may include an underactive thyroid, low vitamin B12 or vitamin D levels, and anemia (low blood count). Factors such as sleep problems and side effects of medications can also play a role. For example, metformin may play a role in lowering vitamin B12 levels, resulting in PCOS fatigue.
If you haven’t been checked out for other contributing causes of fatigue, talk to your doctor about further evaluation. Conditions like hypothyroidism, low vitamin B12, and anemia are treatable. Your doctor or pharmacist can identify drug and supplement side-effects or interactions that may be causing your PCOS fatigue and recommend adjustments to your regimen. Also, too little sleep can affect energy, mood, and other symptoms such as pain.
Causes and Treatments for Hirsutism with PCOSWhat is Hirsutism?
Hirsutism is the excessive growth of facial or body hair on women. Hirsutism and unwanted PCOS facial hair are very common with polycystic ovary syndrome. Hirsutism can be seen as coarse, dark hair that may appear on the face, chest, abdomen, back, upper arms, or upper legs. Hirsutism is a symptom of medical disorders associated with the hormones called androgens.
Hirsutism is very common and often improves with medical management. Prompt medical attention is important because delaying treatment makes the treatment more difficult and may have long-term health consequences.
Effects of Androgens on Hair Growth
An overabundance of facial and body hair is usually the result of excess androgens in your body. Androgens are present in both men and women, but men have much higher levels of biologically active androgens. In women, androgens are produced by the ovaries and the adrenal glands.
If your hair follicles are hormone-sensitive, androgens may cause some vellus hairs to change to terminal hairs. Terminal hair is longer, darker, and more coarse than vellus hair, and grows faster and thicker.
Androgen-sensitive areas of hair growth include:
Upper lip
Beard area
Breasts
Lower abdomen
Inner thighs
Lower back
Diagnosing Hirsutism
Reproductive and medical endocrinologists are trained to treat hirsutism. Some gynecologists, dermatologists, and general practitioners also have the necessary expertise to help with this problem.
If you are diagnosed with hirsutism, your physician may perform blood tests, an ultrasound, special x-rays, and hormone tests to evaluate the function of your ovaries and adrenal glands.
Drugs that Curb Androgen Levels
Drugs that curb androgen levels are another common treatment used for PCOS, although they are not officially FDA-approved for PCOS treatment. By lowering androgen levels, many patients have significant improvements in androgen-related symptoms such as excess hair. Spironolactone is the anti-androgen drug most often used.
To curb hirsutism (excess hair), Dr. Andrea Dunaif from Northwestern University typically starts patients with spironolactone. A 6-month trial is needed to show effects on unwanted hair, and she usually starts women at a higher dose. The unwanted hair doesn’t disappear; it grows in finer and lighter. Improvement of acne generally comes more quickly. Unfortunately, this drug is unlikely to help with androgen-related hair loss (aka androgenic alopecia) which is more difficult to treat.
Two important things to note are that the long-term safety effects of use are not known (but the drug has been in use for decades already) and spironolactone IS NOT SAFE in pregnancy, so it is commonly used in conjunction with birth control pills. This use of birth control pills also protects against abnormal growth of the lining of the uterus. Some women cannot take birth control pills, in which case it is important to use other means of birth control if you are sexually active while taking spironolactone.
Laser Therapy and Electrolysis
Treatments targeting the skin or hair more directly are also available to help with hair problems. These include the prescription cream eflornithine hydrochloride (Vaniqa), acne products, and cosmetic treatments such as laser therapy and electrolysis.
Laser treatments may be used on large areas of the body. During a laser hair treatment, a beam of light is passed through the skin to the hair follicle to destroy it. People with light skin and dark hair usually achieve the best results with laser hair removal.
During electrolysis, a very fine needle is inserted into the hair follicle. A mild electric current is sent through the needle to permanently destroy the hair follicle’s ability to produce hair. Since follicles are treated one at a time, it is somewhat impractical to use electrolysis to treat very large areas of the body.
Both methods of hair reduction are moderately painful, depending on the area of skin being treated, and multiple treatments usually are required. Nevertheless, electrolysis and laser therapy are very effective ways to remove unwanted hair. However, they may not reduce all hair growth and may not always be permanent.
If you are diagnosed with hirsutism or have unwanted PCOS facial hair, your goals and concerns can be addressed in a relatively short period of time, and treatment often is successful.
PCOS and Pregnant? Questions Answered
Women with polycystic ovary syndrome (PCOS) are at higher risk for certain problems or complications during pregnancy. Some women may not realize they have PCOS until they try to conceive. PCOS often goes unnoticed until pregnancy. But if you’ve been trying to conceive naturally for over a year, you should speak to your doctor about getting tested.
Your doctor can help you develop a plan for getting pregnant. Some strategies, such as losing weight, healthy eating, and in certain cases, medications, can increase your chances of getting pregnant.
Women with PCOS are at higher risk for pregnancy and delivery complications. These include a three-fold increase in miscarriage risk in early PCOS pregnancy compared to women without PCOS, gestational diabetes (diabetes during pregnancy) which can lead to large babies, preeclampsia which is characterized by sudden elevated blood pressure and body swelling after the 20th week of pregnancy, preterm birth, and C-section delivery.
If you develop preeclampsia during your pregnancy, you will have to be monitored extremely closely because it can affect the mother's kidneys, liver, and brain.
Diabetes during pregnancy is a concern many women with PCOS must face. If you develop gestational diabetes, insulin may be required to keep your blood sugar levels stable. Gestational diabetes could result in problems during delivery. For example, larger babies are more at risk for shoulder dystocia (when the baby’s shoulder gets stuck during labor).
The following information is published with permission from the Hormone Health Network, the public education arm of the Endocrine Society. It has been extracted from the Diabetes and Pregnancy patient guide.
Blood glucose. While pregnant, you will probably need to check your blood sugar more often than before pregnancy. Check your blood sugar as often as your doctor recommends. You should probably test it before meals, one or two hours after a meal, at bedtime, and during the night.
Ask your doctor what your blood glucose numbers should be. Most pregnant women with diabetes should aim for these blood sugar levels as long as they do not cause low blood sugar:
Before meals (fasting blood glucose)
One hour after the start of a meal: 140 mg/dL or less
Two hours after the start of a meal: 120 mg/dL or less
Insulin. If you were already using an insulin pump before pregnancy, you should keep using it. You probably should not start using an insulin pump for the first time during pregnancy. But if other types of insulin treatment do not control your blood sugar, your doctor may want you to switch to an insulin pump.
Medical nutrition therapy. You should see a dietitian for nutrition therapy. This healthy eating plan, tailored to you, helps make sure you get the nutrients you need and gain the right amount of weight while controlling your blood sugar.
The dietitian may suggest you limit the level of carbohydrates, or “carbs” (for instance, potatoes, bread, and fruit) that you eat. It is a good idea to eat three small meals and two to four snacks a day. Your dietitian also will advise how often to eat and how many calories to eat a day.
The most important thing is to make sure your diet is full of nutrient-rich foods and adequate protein, and low on high-sugar foods. Avoiding junk food and processed foods is your best bet.
Proper medical management and medical nutrition therapy are imperative to prevent the onset of medical complications and optimize fetal growth and development.
Exercise. Postmeal physical activity, such as walking for 10 to 20 minutes, can help manage blood pressure and insulin resistance by controlling postprandial hyperglycemia.
Yoga has also been shown to be especially effective in improving fertility and PCOS. It’s important to understand that yoga will not cure your PCOS, but will help you feel more connected to your body, restore hormone balance, and can help increase blood circulation to the pelvic region.
Vitamins. Your doctor likely will decrease the dose of folic acid you take once you finish your first trimester of pregnancy (week 12). Most often, the recommended dose of folic acid is 0.4 mg (400 micrograms) to 1 mg per day through the rest of pregnancy and until you stop breastfeeding. Ask your doctor what other prenatal vitamins you need.
If you’re diagnosed with PCOS, you may need to continue to manage symptoms even after pregnancy. But symptoms and severity can vary. Sometimes the hormonal fluctuations after pregnancy and breastfeeding can change the symptoms, so it may be a while before you settle into your new “normal.”
Women with diabetes are encouraged to breastfeed their babies. Breastfeeding lowers your baby’s risk for childhood obesity and for type 2 diabetes later in life. Women with gestational diabetes have an increased risk of developing type 2 diabetes, but breastfeeding seems to lower that risk. It also may help you lose the weight you gained during pregnancy!
Insulin is safe for breastfeeding women. If you take metformin or glyburide pills to treat type 2 diabetes, you can safely continue taking these medications while breastfeeding.
Trouble with Milk Supply?
Lactation consultants recommend that all women with PCOS pump after feedings for at least 10 to 15 minutes on each breast to help establish an adequate milk supply in the first two weeks of initiating nursing.
Frequent feedings with full drainage can also help maximize milk production, as can consuming an adequate amount of food and fluid each day.
Milk supply problems may be prevented by establishing early intervention strategies during pregnancy. This may include obtaining resources for local breastfeeding support groups and preparing to work with a board-certified lactation consultant. Good breastfeeding management, including proper latch and positioning, are imperative to successful milk production and proper infant growth and development.
There are some risks for your baby, including premature birth, growing unusually large for the gestational age, miscarriage, or lower Apgar score. If your baby is a girl, there is also a greater chance that she will develop PCOS.
You can help ensure your baby’s health and your own health. Work with your obstetrician and your diabetes specialist to get proper medical care before, during, and after pregnancy. Take your diabetes medicine as prescribed and keep your blood sugar under control. Follow the healthy eating plan that you made with your health care team. Also, be physically active. Ask your doctor what type of activity is best for you.
The good news is that with careful planning, proper medical care, and good self-care, you can have a safe PCOS pregnancy and healthy baby.
How to Treat PCOS
PCOS treatments focus on managing your individual concerns, such as infertility, hirsutism, acne, or obesity. PCOS treatments can include lifestyle changes like healthy eating and losing weight, or in some cases, medications can help. If a woman is not seeking to become pregnant, hormonal birth control (most often birth control pills) is a standard treatment.
Birth control pills. This is a common treatment to regulate periods and limit excess hair growth and acne by lowering androgen levels and protecting the endometrium (inner lining of the uterus) against abnormal cell growth. Regulating your hormones can lower your risk of endometrial cancer.
Pills that contain estrogen and progestin decrease androgen production and regulate estrogen. Older types of birth control pills have a lower risk for dangerous blood clots and are preferable over new types of birth control pills.
Instead of pills, you might prefer to use a skin patch or vaginal ring that contains a combination of estrogen and progestin.
Metformin. Although metformin is not approved by the FDA for the treatment of PCOS, many doctors prescribe it for PCOS patients. Metformin is a medicine that makes the body more sensitive to insulin. This can help lower elevated blood glucose levels, insulin levels, and androgen levels. People who use metformin may lose some weight as well. Metformin can improve menstrual patterns, but metformin doesn’t help as much for unwanted excess hair.
Many women who are diagnosed with PCOS are often automatically prescribed metformin. However, it's important to have a reason for taking metformin and not be on it just because of a diagnosis of PCOS. Discuss with your doctor the reason why you are taking metformin and whether it is providing a benefit to you.
Clomiphene (Clomid). This is an oral medication that is the most common treatment used to induce ovulation. The use of both metformin and clomiphene has about the same fertility results as clomiphene used alone. A benefit is that metformin may help reduce the risk for ovarian hyperstimulation syndrome (OHSS) (see also "What is ovarian hyperstimulation syndrome?”) during assisted reproductive technology (ART) fertility treatments.
Letrozole (Femara). Other treatments to stimulate ovulation include another oral medication called letrozole (Femara) and gonadotropins which are hormones that are given by injection. In vitro fertilization (IVF) and in vitro maturation (IVM) may be other fertility treatment options.
Lifestyle changes. Your doctor may recommend weight loss through a low-calorie diet combined with moderate exercise activities. Lifestyle measures to achieve a weight loss of 5%-10% in overweight women can help regulate ovulation and periods. Although the basic approach of nutrition is needed, it can be more challenging to lose weight and maintain weight loss with PCOS. Dr. Dunaif from Northwestern is very encouraged that even “a little bit of weight reduction and exercise can improve insulin sensitivity.”
Spironolactone. Drugs that curb androgen levels are another common treatment used for PCOS, although they are not officially FDA-approved for PCOS treatment. By lowering androgen levels, many patients have significant improvements in androgen-related symptoms such as excess hair. Spironolactone is the anti-androgen drug most often used.
To curb hirsutism (excess hair), Dr. Andrea Dunaif from Northwestern University typically starts patients with spironolactone. A 6-month trial is needed to show effects on unwanted hair, and she usually starts women at a higher dose. The unwanted hair doesn’t disappear but grows finer and lighter.
Improvement of acne generally comes more quickly. Unfortunately, this drug is unlikely to help with androgen-related hair loss (aka androgenic alopecia) which is more difficult to treat.
Two important things to note are that the long-term safety effects of use are not known (but the drug has been in use for decades already) and spironolactone IS NOT SAFE to take during pregnancy, so it is commonly used in conjunction with birth control pills.
This use of birth control pills also protects against abnormal growth of the lining of the uterus. Some women cannot take birth control pills, in which case it is important to use other means of birth control if you are sexually active while taking spironolactone.
Prescription creams. Treatments targeting the skin or hair more directly are also available to help with hair problems. These include the prescription cream eflornithine hydrochloride (Vaniqa), acne products, and cosmetic treatments such as laser therapy and electrolysis.
Vitamins.
Vitamins, supplements, and other complementary treatments are popular among women with PCOS. Researchers are studying the effectiveness of such treatments. Popular treatments include cinnamon, Myo-inositol, vitamin D, B complex vitamins, and acupuncture. We hope to share and explain the evidence for these and other treatments as well as research findings as they develop.
HealthySmartsMD also aims to aggregate data to provide collective evidence of the effectiveness or ineffectiveness of the various vitamins, supplements, and other complementary and alternative treatments women are trying on their own for PCOS.
Because the severity of PCOS can vary from person to person, treatment plans are highly individual. It’s extremely important to talk to your doctor about all potential treatment options. Remember to consider factors such as cost, desire to have children in the future, regular periods versus irregular bleeding, and effectiveness at preventing pregnancy if you’re not trying to conceive right now.
In October 2013, the Endocrine Society released new guidelines for diagnosis and PCOS treatments.