story by

Karen Krakower

As if our teenaged girls didn't have enough body-image mixed-signals just dealing with the normal changes puberty brings. Add too much male hormone, and you've got a rite of passage—gone wrong.

Six to 10 percent of our nation's young women suffer from a collection of disturbing symptoms called Polycystic Ovary Syndrome (PCOS). Not only can it lead to infertility, but in the obese patients it also is a giant red flag for diabetes and heart disease.

PCOS is one of the most common and confusing female endocrine disorders today, says endocrinologist Dr. Shahla Nader of The University of Texas Medical School at Houston. "If untreated, some of these girls can progress to type 2 diabetes (noninsulin dependent), cardiovascular problems and eventually endometrial cancer, not to mention infertility."

Physical symptoms vary widely, but common to many girls with PCOS are the following signs, many of them relating to excessive androgens (male hormones):

• severe acne
• loss of scalp hair similar to male pattern baldness, including a receding hairline
• excess body and facial hair in a male pattern of hair growth
• skin pigmentation on neck, under breasts and arms (acanthosis nigricans)
• excessive oiliness of skin and hair
• menstrual irregularities or absence of periods altogether
• obesity is present in many but not all PCOS patients. The obese patients (particularly those who carry their weight in an apple shape, more than a pear) are also at higher risk for diabetes and heart disease.

Clinical or laboratory features may include:

• high androgen levels (male hormone such as testosterone)
• high insulin levels
• glucose level abnormalities
• ovaries (seen on ultrasound) may be enlarged and have a "string of pearls" appearance--tiny beads under the top layer of the ovarian tissue (this feature is not required for diagnosis).

The key to diagnosis is finding out why these young girls, whose symptoms manifest any time between puberty and early 20s, have high male hormones in the first place. Insulin resistance leading to high insulin blood levels is often the culprit.

Male hormones are produced in two locations: the ovaries and the adrenal glands. Early thought led investigators to believe that too much androgen in females was an adrenal glitch. "And, some patients have this, but most of what I see is ovarian hyperandrogenism, which is where we start the insulin story," Nader explains.

Medical detectives
ask the right question

About 30 years ago a group of Boston investigators interested in insulin action found that there were women with rare conditions leading to insulin resistance. The body's reaction to this is overproduction of insulin. What no one realized at the time was that insulin resistance, to varying degrees, is common within the general population and exacerbated by obesity. When there is resistance to insulin, the pancreas goes crazy trying to normalize sugar levels in the blood, producing even more insulin.

These young women with high insulin levels were also found to have hirsutism: male pattern hair growth, including hair on the chin and upper lips and pubic hair that tends to extend upward towards the navel.

They also had irregular or no periods and high testosterone levels. "It took a long time for the medical community to finally ask the right question, 'What does insulin have to do with male hormone in women?'"

Which led to the right answer: insulin is a hormone and, in high levels, stimulates the ovaries to produce too much androgen. In girls with PCOS, puberty creates a domino effect starting with insulin's stimulation of ovarian androgen overproduction, which throws a young girl's developing body into chaos.

Who's at risk

Poor eating habits and lack of exercise contribute to the development of PCOS. Insulin resistance is more prevalent in African-American and Hispanic groups. And if you come from a family predisposed to insulin resistance or Type 2 diabetes, "and then add the environmental factor of obesity and inactivity, you've got what I call 'The Double Whammy,'" Nader says.

In her practice she sees many new patients a week presenting with symptoms of PCOS. "I ask them one question first: how much of the 50 to 100 extra pounds that you're carrying were gained since the age of 15?"

Treatment? You bet.

Though it cannot be "cured," PCOS can be treated with a whole host of therapies, as long as the patient is willing to advocate for her own health, in partnership with her physician. But the commitment is lifelong.

• Diet and exercise. "Exercise improves insulin action and the utilization of glucose," Nader says. Nutritionally- sound weight loss helps reduce the amount of circulating glucose and insulin.
  
• Reproductive hormone therapy, such as the simple birth control pill, lowers male hormones which helps alleviate symptoms like acne and hair loss, and can reduce the risk of endometrial cancer. However, while birth control pills may help the hormonal issues and patient symptoms, in the obese patients, they can potentially worsen the metabolic situation. This is why insulin sensitizers are often prescribed along with the birth control pill to obese patients.
  
• Androgen blockers reduce the byproducts of too much testosterone, such as hirsutism. Androgen blockers take several months to become effective. They prevent new hair growth, but will not get rid of old hair. Only electrolysis will permanently destroy the old hair.
  
• "Insulin sensitizers, which can lower insulin and androgens, are often used off label (for a purpose other than an FDA-approved use), even if the patient isn't yet diabetic," Nader says.

Patients are then closely monitored to see if the drugs are working and if the girls are working to maintain their weight and continue to exercise.

Infertility

Infertility is a classic reason that brings these women to a doctor. “Most of these young women have never had regular periods, if they menstruate at all, and now they wish to conceive. Without treatment, they will not.”

When it comes to fertility treatment, patients are first monitored to see if they can ovulate on their own. If not, fertility drugs, insulin sensitizers and other treatments have proven effective. "We have several treatments in our arsenal," Nader reassures.

Nader cautions that PCOS is a mulit-faceted syndrome. Other disorders mimic it, and no two patients are identical. Some PCOS patients don't have ovaries that appear cystic. Some do, but are not obese. In addition, not every patient with high androgen is insulin resistant, and in fact, there are other potential causes for excessive androgen production.

"Though there are certain criteria that demonstrate some commonalities, this syndrome is still the perfect example of the eight blind men describing an elephant. Where we can all agree is that PCOS is becoming a serious public health issue, especially given the increase in obesity in our young girls. This will have devastating effects if left untreated."

Thankfully PCOS can be identified at early onset, before life-altering damage sets in. "How many diseases do we have a 30-year window of opportunity to make a difference? This one — but the patient's efforts are as important as the doctor's."

UPDATED: 5-24-2007

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