Polycystic Ovaries Syndrome
Dr. Nelson Soucasaux , Brazilian gynecologist
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
menovulatory period of women's lives), 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 10-15 mm. The follicles that have the possibility of ovulating (usually
called mature follicles) may reach the size of 20 to 25 mm. 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, about ovarian cysts in general, we must observe that, during
women's fertile years, only cysts with more than 35-40 mm 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 the incidence of ovarian cancer is 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
4 to 7mm), 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 about "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).
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 levels
of LH are usually significantly greater than those of FSH (follicle stimulating
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
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
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.
Copyright Nelson Soucasaux 2002
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, Brazil, 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,
Website (Portuguese-English): www.nelsonginecologia.med.br
© 2002 Harry Finley. It is illegal
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