The "bound up" testosterone is fairly un-reactive. The free testosterone is what causes the classical male hormone-like effects—hair growth, acne, and disruption of normal ovulation and cycling. There accumulates a collection of early follicles that don't go any further. (An ovary in such a state, by the way, is "loaded" and on a trigger edge such that there will be an exaggerated response to induction of ovulation, with a greater risk of twins and triplets from multiple simultaneous ovulations.)
Exacerbating Factors of PCOS
The "full-blown typical" PCOS patient has a history of only occasional ovulations (less than eight per year) and prolonged cycles of greater than 35 days, male-like hair distribution or male-pattern hair loss, obesity, multiple ovarian cysts, acne, and a laboratory assessment demonstrating too much testosterone. But there are varying degrees of PCOS, and many women with the syndrome have only a few or isolated aspects of the disorder. Although insulin resistance is independent of weight, being overweight can make it worse. Most patients with PCOS are advised to lose weight.
Other things besides PCOS can cause an increase in testosterone. Since this hormone is also produced in the adrenal gland, disorders (including cancer) of the adrenal need to be considered and/or ruled out. Care of a patient with PCOS includes testing for diabetes (fasting blood sugar, HbA1c), abnormal lipids (cholesterol, triglycerides, etc.), and measuring the amount of insulin resistance (with a glucose-to-insulin ratio).
Aproaches for Treatment
Treatment goals are:
- Reduce hair-growth problems and acne.
- Manipulate the cycles hormonally to re-establish regular menstrual periods. (Remaining in the first part of the cycle for too long can lead to overstimulation of the uterus by estrogen and possibly lead to uterine cancer.)
- Re-establish fertility by re-establishing ovulation (if pregnancy is desired).
If a woman with PCOS isn't seeking pregnancy, birth control pills will effectively create artificial cycles that will prevent irregular bleeding, prevent a tendency to uterine cancer, and decrease the amount of testosterone produced by the ovaries.
If a woman seeks pregnancy, ovulation inducers like Clomid can be used. Some infertility doctors also give insulin-sensitizing agents such as metformin (which re-sensitize the insulin, another way to describe a lowering of insulin-resistance).
Re-sensitizing insulin (lowering insulin-resistance) will mean a lowering of insulin response levels closer to normal, with a mitigation of all aspects of PCOS. Spironolactone, which is actually a diuretic ("fluid pill"), competes with testosterone at the sites where testosterone acts on tissue. It is often used as additional therapy, but this drug may mess up potassium levels and have other side effects, like other diuretics.
PCOS is not quite the disorder Drs. Stein and Levinthal originally thought it was, but they were a crucial beginning in helping women by recognizing the link between certain symptoms and an abnormal medical condition. The importance of their findings is only now being appreciated as we're beginning to see PCOS as it relates to heart disease, infertility, and diabetes.
These pioneering doctors can be compared to Columbus, "discovering" what they thought was something else, but beginning a whole new world of help for women.