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"Polycystic
Ovaries Syndrome" Nelson Soucasaux |
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In different
intensities, degrees and clinical manifestations, the so-called "polycystic
ovaries syndrome" constitutes a functional and hormonal disorder
frequently found in gynecologic practice. Though fundamentally caused
by several alterations in the functioning of the intricate mechanisms
of the hypothalamus-pituitary-ovaries axis and sometimes including disorders
in other areas of the endocrine system, Gynecology is still insisting
on trying to find out which should be the "ultimate cause" for
this complicated disorder. The unfortunately strong reductionist approach
that dominates present-day medicine is responsible for that kind of attitude,
making most colleagues forget that, in fact, rather than "ultimate"
or "single" causes for many medical disorders, there is always
a multiplicity of factors and "causes" that interact, resulting
in the establishment of most disturbances and diseases. I believe this
is also true for the still mysterious "polycystic ovaries syndrome".
I also have
some reservations regarding the term "polycystic ovaries" for
that disorder, because it causes considerable conceptual confusion on
patients. In my opinion, this condition should be much better defined
as "polymicrocystic ovaries", since the follicular cysts found
in it are very small and do not reach the size of the mature follicles
of the normal ovarian cycles. A brief explanation about what happens throughout
the normal ovarian cycles becomes necessary here. Along the menacme (
the period of women's lives in which they menstruate ), several follicles
in various stages of growth and involution are physiologically found in
the ovaries according to the phase of the cycle. They are easily verified
at ultrasound examinations as "follicular cysts", and their
size vary from an average of 5 to 10 -15mm. The follicles that have the
possibility of ovulating ( usually called mature follicles ) may reach
the size of 20 to 25mm. Therefore, the presence of ovarian "follicular
cysts" is a normal event during the fertile years of women's lives.
For that reason, in a way we could consider the ovaries as being frequently
"polycystic" organs, according to the phase of the cycle.
By the way,
regarding ovarian cysts in general, we must observe that, during women's
fertile years, only cysts with more than 30-35mm usually require special
medical attention. Conversely, in post-menopausal women all ovarian cysts
demand great attention and need to be carefully investigated, because
in that period the possibility of follicular functional cysts does not
exist anymore due to the complete depletion of the follicular population
of the ovaries, and also because, in post-menopause, the incidence of
ovarian cancer becomes greater ( Note 1
).
Returning to
our main subject and considering all of this, what actually does happen
in the usually called "polycystic ovaries syndrome" ? One
of the answers is: in that disorder, due to its several causes, the growth
of all follicles is prematurely interrupted, and no one of them usually
reaches the stage of mature follicle. The result is chronic anovulation
and the presence of a great number of follicles forming small cysts (
about 5 to 8mm ), always associated with a typical hyperplastic alteration
of the ovarian stroma named hyperthecosis. The ovarian tunica albuginea
( the thin external fibrous coating of the ovaries ) is thickened, and
the ovaries become bilaterally enlarged as the disorder aggravates. It
is important to remark that we only can speak on "polycystic or polymicrocystic
ovaries syndrome" in the presence of all of these alterations. The
ultrasound examination of the ovaries usually reveals the presence of
several small follicular cysts always associated with an increased density
of the ovarian tissues and, almost always, a bilateral enlargement of
these organs.
The more frequent
clinical manifestations of the "polycystic ovaries syndrome"
are: 1) long-lasting cycles ( oligomenorrhea ) and/or episodes of amenorrhea;
2) excessive growth of hair on several areas of the body ( hypertrichosis
or hirsutism ), frequently associated with acne; 3) chronic anovulation
and infertility ( though occasional and rare ovulations may occur ). Some
patients exhibit a tendency to weight gain or even obesity. The menstrual
disorders may also include episodes of excessive uterine bleeding ( hypermenorrhea
and/or menorrhagia ).
As I have mentioned
before, the "polycystic ovaries syndrome" is the final result
of a series of disorders in the hypothalamus-pituitary-ovaries axis, sometimes
also involving other endocrine alterations. The disorders of the ovarian
cycle, mostly characterized by anovulation, oligomenorrhea and/or amenorrhea,
are due to a failure in the extremely complex feedback mechanisms between
the ovaries and the hypothalamic-pituitary system, with a consequent loss
of the cyclical feature that characterizes the normal ovarian function.
Increased blood levels of LH ( luteinizing hormone ), relative or absolute,
can be found, and the ovulatory peak of this gonadotropin is almost always
absent along the cycles. Comparatively speaking, the basal levels of LH
are usually significantly greater than those of FSH ( follicle stimulating
hormone ).
The hypertrichosis
and/or hirsutism, as well as acne, are a consequence of the heightened
levels of androgens ( androstenedione and testosterone ) frequently produced
by the "polycystic ovaries". A brief explanation about the sexual
hormones synthesis in the ovaries becomes necessary here. Due to a curious
biochemical peculiarity, physiologically the female hormones ( estrogens
) are always produced having male hormones ( androgens ) as precursors.
This means that, in order to produce estrogens ( the hormones of femininity
), women have to previously produce androgens. In the ovarian follicles,
the androgens androstenedione and testosterone are respectively turned
into the estrogens estrone and estradiol. The ovarian androgens are produced
under the LH stimulation, and their transformation into estrogens takes
place under the FSH stimulation.
For several
reasons not entirely elucidated yet, in the "polycystic ovaries syndrome"
there is an excessive production of androgens, causing the hypertrichosis,
hirsutism and acne. This heightened androgen production by the ovaries
also inhibits the normal process of follicular maturation, collaborates
to maintain the hypothalamic-pituitary acyclical disorder and the consequently
altered levels of LH. These heightened LH levels, in turn, increase the
aforementioned ovarian hyperthecosis and bilateral enlargement, aggravating
the disturbance and making the ovarian androgenic production becomes higher
and higher. Therefore, the final result is the establishment of a vicious
circle. We must also remark that, in some cases of "polycystic ovaries",
an increased production of androgens by the adrenal glands may also be
present ( Note 2 ).
Nevertheless,
we must emphasize that not all women with hypertrichosis ( mostly when
it is slight or moderate ) present heightened androgen levels or "polycystic
ovaries". In many of these cases, the androgen levels are normal,
and the excessive growth of hair on the body is due to an increased sensitivity
of the hair follicles to normal androgen levels. These cases constitute
what we use to call "constitutional hypertrichosis or hirsutism".
Presently, some disorders in the insulin metabolism ( mostly the one called
insulin-resistance ) are being found in many women with "polycystic
ovaries syndrome". This fact is making many researchers attribute
great importance to this "insulin-resistance" on the genesis
of the syndrome, and they argue that this metabolic disorder can increase
the production of androgens by the ovaries. Nevertheless, in my opinion,
this new theory on the "origin" of the intricate and multifactorial
"polycystic ovaries syndrome" only reveals one more aspect of
the disturbance. Even so, the fact is that the aforementioned association
between the "polycystic ovaries syndrome" and disorders in the
insulin metabolism constitutes an entirely new subject in Endocrine Gynecology,
and presently many authors are carrying out detailed studies on it.
Finally, I
want to emphasize that the correct diagnosis of "polycystic or polymicrocystic
ovaries" demands as minimum requirements a careful analysis of the
clinical manifestations, a meticulous hormonal evaluation and an accurate
ultrasonographic study of the ovaries. There are and there have been several
treatments for the manifold manifestations of the "polycystic ovaries
syndrome", and usually the specific therapy to be used depends on
the aspect of the syndrome that worries and affects each patient the most.
Note
1: Another
explanation concerning ovarian cysts in general is also very important
here. Briefly we can say that there are basically two kinds of ovarian
cysts: the functional and the neoplastic ones. Functional cysts originate
from the ovarian follicles ( and sometimes from the corpus luteum ), and
include not only the normal growing follicles usually found along the
ovarian cycle, but also follicles that, due to a functional disorder,
become exceptionally enlarged. On the other hand, most neoplastic cysts
do not originate from the ovarian follicles, and their histologic structure
is quite different from that of these follicles. Sometimes neoplastic
cysts may become malignant. While the treatment of functional cysts is
clinical ( and some of them may even diminish and disappear spontaneously
), the treatment of the neoplastic ones is surgical. As to our main subject,
it is important to remark that the cysts found in the "polycystic
ovaries syndrome" are functional.
Note
2: While some authors believe that the original or "primary"
disorder responsible for the "polycystic ovaries syndrome" lies
at the ovarian level, others believe that it lies at the hypothalamic-pituitary
level. The fact is that, as we have already said, both the ovaries and
the hypothalamic-pituitary function are deeply altered, creating a vicious
circle. Besides the functional disturbance, the ovaries also exhibit considerable
histologic and morphologic alterations, mostly characterized by the hyperthecosis
( hyperplasia of the ovarian stroma ) and the bilateral enlargement of
these organs. As it was also observed, an excessive production of androgens
by the adrenal glands ( hyperandrogenic adrenal hyperplasia ) may also
be responsible for several cases of "polycystic ovaries syndrome",
and sometimes both conditions may be associated.
Nelson Soucasaux
is a gynecologist dedicated to Clinical, Preventive and Psychosomatic
Gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade
Federal do Rio de Janeiro, he is the author of several articles published
in medical journals and of the books "Novas
Perspectivas em Ginecologia" ("New Perspectives in Gynecology")
and "Os Órgãos Sexuais Femininos:
Forma, Função, Símbolo e Arquétipo" ("The
Female Sexual Organs: Shape, Function, Symbol and Archetype"),
published by Imago Editora, Rio de Janeiro, 1990, 1993.
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