"Polycystic Ovaries Syndrome"

Nelson Soucasaux

Nelson Drawing 1979

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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