Polycystic ovary: therapies

Polycystic ovary syndrome is a far from rare female problem. Fighting it with the right therapies also allows fertility to be safeguarded.

Polycystic ovary syndrome, also called ovarian polycystosis, is a rather frequent endocrine disorder: it affects 5 to 10% of women of childbearing age (it tends to occur from puberty), and is considered the most frequent cause of female infertility.

As you can guess from the name, in fact, the ovaries appear enlarged and covered with cysts, that is, many small rounded formations that are the result of the lack of maturation of the follicles from which the egg cells are normally freed. In practice, ovulation does not occur or is irregular and because of this it becomes difficult to conceive a child. Facing it with adequate therapy, therefore, becomes important also in view of a future pregnancy.

It’s a hormonal problem

Polycystic ovary is an endocrine disorder characterized by hyperandrogenism, i.e. excessive production at the ovarian level of male hormones (androgens), in particular testosterone.

Precisely the excess of these hormones is at the origin of a series of signs that characterize polycystosis such as:

– hirsutism, i.e. excess hair in areas of the body where it is normally present in men and not in women, such as the face, abdomen, back, breast (especially around the areola)

– acne, also on the back and décolleté

– androgenetic alopecia (hair loss similar to male hair)

– oily skin and hair

– menstrual disorders, such as irregular, poor or prolonged menstrual cycle and absence of menstruation for several months (amenorrhea).

We must not forget that these symptoms, also in consideration of the fact that they generally occur during adolescence, contribute to creating not only physical but also psychological discomforts, depressive forms and difficulties in interpersonal relationships that should not be underestimated.

It is also a metabolic disease

For some years ovarian polycystosis has also been recognized as a metabolic disease: in addition to the known and already described clinical symptoms, in fact, about 25-50% of patients deal with obesity or overweight and one in two has compensatory hyperinsulinemia, ie an excessive production of insulin (the hormone that regulates blood sugar) as a result of a condition of resistance by the body to the action of the same (insulin resistance).

The condition of overweight or obesity of women with polycystosis is generally of the android type: the accumulation of fat is mainly in the abdomen, which represents an important risk factor in particular for cardiovascular diseases.

According to several studies, patients with ovarian polycystosis have an increased risk of developing glucose intolerance and type 2 diabetes mellitus, but also hypertension, excess cholesterol and cardiovascular pathologies after the age of 35-40. The risk of type 2 diabetes, in particular, would be 5 to 10 times greater.

Those suffering from polycystic ovaries are also more at risk of developing gestational diabetes in a possible pregnancy. Overweight and obesity also contribute to worsening the specific picture of the disease, because fat tissue in turn produces estrone (a type of estrogen negative for health), inflammatory molecules and additional male hormones.

The mechanisms at the origin of polycystic ovary are not yet well understood. In medicine, the hypothesis has recently made its way that insulin resistance and compensatory hyperinsulinemia play a role among the possible causes: according to recent studies, in fact, high levels of insulin in the ovary would favor the lack of ovulation and the excessive production of androgens.

Insulin in particular seems to favor, at the level of the ovaries, the conversion of a naturally present molecule, a sort of sugar called myo-inositol, into a variant, D-chiro-inositol. Since the former normally acts as a messenger of the FSH hormone, which has the task of stimulating ovulation, its deficiency results in the lack of ovulation, while the excess of the latter promotes excessive androgen production.

Diagnosing polycystic ovary

To set the correct treatment of ovarian polycystosis, a precise diagnosis is first of all necessary. For this purpose, a gynecological examination, an ultrasound of the ovaries and blood tests with hormonal dosage are generally necessary.

You can therefore speak of polycystic ovary if you find at least two out of three of the following symptoms:

– clinical signs (symptoms visible at medical examination) or chemical signs (i.e. found in blood tests) of hyperandrogenism;

– oligomenorrhea or amenorrhea (alteration of the rhythm of the menstrual cycle or its absence) and/or failure to ovulate;

– ovaries that on ultrasound appear enlarged and polycystic, that is, more than 15-20 immature follicles on the outer margin.

If polycystosis is confirmed, the doctor may also arrange further tests: the American Congress of Obstetricians and Gynecologists recommends, for example, a glucose load test and a lipid profile analysis, for a metabolic evaluation.

Once the diagnosis has been made, it is up to the doctor to propose a treatment strategy that counteracts the symptoms and allows to prevent infertility. There are different possibilities of therapy, the choice of which also depends on the woman’s willingness to immediately seek pregnancy or not.

Lifestyle change

The first step for the treatment of ovarian polycystosis, indicated both for women who aim for a pregnancy in a short time and for others, consists in a change in lifestyle habits, in particular those related to nutrition and physical activity, especially if the patient also has obesity or overweight problems, defined according to the value of the body mass index (BMI):

Underweight	BMI < 18.4
Normal weight	BMI 18.5-24.9
Overweight	BMI 25-29.9
First-degree obesity	BMI 30-34.9
Obesity of the second degree	BMI 35-39.9
Obesity of the third degree	BMI ≥ 40

It is advisable, in particular, to follow a diet that limits foods with a high glycemic index (which cause a rapid increase in the concentration of sugar in the blood) such as sweets, refined cereals and yeasts, favoring vegetables and fruits that are not very sweet, fish and white meats, whole grains, legumes, to be combined with aerobic physical activity (such as jogging, swimming, cycling) daily (for at least 45 minutes a day), which stimulates the metabolism even at rest and optimizes the use of insulin.

In many cases, just regaining a healthy weight allows ovulation to return and helps reduce overall risk factors. However, you should not opt for do-it-yourself, but it is better to rely on the guidance of specialists, such as a nutritionist. The approach should be multidisciplinary and, especially if the discomfort caused by the other symptoms is amplified by the difficulty in losing weight despite diet and physical activity, it may also be useful to rely on the help of a psychologist.

For those who do not want children immediately

For years the only treatment for ovarian polycystosis has been the use of a hormonal contraceptive, the estroprogestin pill, that is, containing in addition to estrogen also antiandrogenic progestogen hormones (such as drospirenone, cyproterone acetate and, more recently, dienogest and norelgestromin).

Today, in addition to the pill, it is possible to use, alternatively, the vaginal ring or the patch, always containing the same types of hormones. The gynecologist will prescribe the most suitable contraceptive after a thorough examination of the woman (hormonal contraceptives, like all drugs, may have contraindications).

These contraceptives put the ovary at rest, preventing the syndrome from worsening over time and, thanks to progestogen hormones, counteract the symptoms related to excess androgens. However, as contraceptives, they are obviously only suitable if the woman is not trying to have a child.

For those who want to get pregnant

For patients looking for a child, the gynecologist can prescribe drugs that can promote ovulation, such as clomiphene citrate, an active ingredient that promotes an overproduction of FSH hormone which, in turn, stimulates the ovaries, follicle maturation and ovulation.

In recent years, polycystic ovary therapy has also begun to be used with drugs that can improve the condition of insulin resistance and indirectly reduce insulin secretion. This is the case of metformin, an active ingredient that is normally indicated in type 2 diabetes, but which has also been tested in ovarian polycystosis: according to a systematic review it was effective in short-medium term therapies (three to six months), promoting ovulation and pregnancy and also improving the effectiveness of pro-ovulatory medicines (such as clomiphene). However, there is still insufficient data on the efficacy and safety of long-term therapy.

The intake of insulin-sensitizing drugs prescribed in case of polycystosis does not cancel the importance of lifestyle change (weight control and physical activity), which remains the first therapeutic choice.

There is also a supplement

According to the most recent studies, supplementation with inositols may also be useful in the treatment of polycystic ovary syndrome. For a year it has been available in pharmacies a supplement designed specifically for polycystosis, which contains a combination of myo-inositol and D-chiro-inositol in a 40 to 1 ratio: while the second acts at the level of the liver reducing insulin resistance and decreasing the circulating insulin that would attack the ovary, the first compensates for the ovarian deficiency of this substance which, As seen, it would result in a missed ovulation.

According to the available data, in 70% of cases it allows the resumption of ovulation after only three months of intake and counteracts the symptoms of hyperandrogenism. It can also be taken during pregnancy, to reduce the risk of gestational diabetes, and in combination with other therapies (in combination with the estroprogestin pill, to optimize the use of insulin and act on the metabolic aspect, or other ovulation drugs, to improve the quality of oocytes).

Like all supplements, it does not require a prescription, but it is always better to take it under the supervision of the specialist. The use of supplementation also does not replace the need for lifestyle modification.