Polycystic Ovary Syndrome (PCOS)

Polycystic (pronounced pah-lee-SIS-tik) ovary syndrome, or PCOS, is a set of symptoms related to a hormonal imbalance that can affect women and girls of reproductive age.

PCOS may cause menstrual cycle changes, skin changes such as increased facial and body hair and acne, cysts in the ovaries, and infertility. Often, women with PCOS have problems with their metabolism also.

About Polycystic Ovary Syndrome (PCOS)

PCOS is a set of symptoms related to a hormonal imbalance that can affect women and girls of reproductive age.

What is PCOS?

PCOS is a set of symptoms related to a hormonal imbalance that can affect women and girls of reproductive age. Women with PCOS usually have at least two of the following three conditions:1

  • Absence of ovulation, leading to irregular menstrual periods or no periods at all
  • High levels of androgens (a type of hormone) or signs of high androgens, such as having excess body or facial hair
  • Cysts (fluid-filled sacs) on one or both ovaries—"polycystic" literally means "having many cysts"

Some women diagnosed with PCOS have the first two conditions listed above as well as other symptoms of PCOS but do not have cysts on their ovaries.

PCOS is the most common cause of anovulatory (pronounced an-OV-yuh-luh-tawr-ee) infertility, meaning that the infertility results from the absence of ovulation, the process that releases a mature egg from the ovary every month. Many women don't find out that they have PCOS until they have trouble getting pregnant.

PCOS can cause other problems as well, such as unwanted hair growth, dark patches of skin, acne, weight gain, and irregular bleeding.

Women with PCOS are also at higher risk for:2

Learn more about disorders and conditions associated with PCOS.

Citations

  1. American College of Obstetricians and Gynecologists. (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS external link
  2. U.S. Department of Health and Human Services, Office on Women's Health. (2014). Polycystic ovary syndrome (PCOS) fact sheet. Retrieved May 20, 2016, from http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html (PDF 126 KB)

What are the symptoms of PCOS?

In addition to the three features used to diagnose polycystic ovary syndrome (PCOS) (absence of ovulation, high levels of androgens, and ovarian cysts), PCOS has many signs and symptoms, some of which may not seem to be related:1,2

  • Menstrual irregularities:
    • No menstrual periods—called amenorrhea (pronounced ey-men-uh-REE-uh)
    • Frequently missed periods—called oligomenorrhea (pronounced ol-i-goh-men-uh-REE-uh)
    • Very heavy periods
    • Bleeding but no ovulation—called anovulatory periods
  • Infertility
  • Excess hair growth on the face, chest, belly, or upper thighs—a condition called hirsutism (pronounced HUR-soo-tiz-uhm)
  • Severe, late-onset, or persistent acne that does not respond well to usual treatments
  • Obesity, weight gain, or trouble losing weight, especially around the waist
  • Pelvic pain
  • Oily skin
  • Patches of thickened, dark, velvety skin—a condition called acanthosis nigricans (pronounced ay-kan-THOE-sis NY-grih-kanz)

Because many women don't consider problems such as oily skin, extra hair growth, or acne to be symptoms of a serious health condition, they may not mention these things to their health care providers. As a result, many women aren't diagnosed with PCOS until they have trouble getting pregnant or if they have abnormal periods or missed periods.

Although PCOS is a leading cause of infertility, many women with PCOS can and do get pregnant. Pregnant women who have PCOS, however, are at higher risk for certain problems, such as miscarriage. Learn more about PCOS-related pregnancy problems.

Citations

  1. American College of Obstetricians and Gynecologists. (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS external link
  2. U.S. Department of Health and Human Services, Office of Women's Health. (2014). Polycystic ovary syndrome (PCOS) fact sheet. Retrieved May 20, 2016, from http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html (PDF 126 KB)

What causes PCOS?

Researchers and health care providers know that genetic and environmental factors contribute to the development of polycystic ovary syndrome (PCOS), but do not know exactly what causes PCOS.

Because the symptoms of PCOS tend to run in families, the syndrome is probably caused, at least in part, by a change, or mutation, in one or more genes. Recent research conducted in animal models suggests that in some cases PCOS may be caused by genetic or chemical changes that occur in the womb.1

PCOS likely results from a combination of causes, including genes and environmental factors.

What causes the symptoms of PCOS?

Most of the symptoms of PCOS are caused by higher-than-normal levels of certain hormones, called androgens.

The ovaries produce hormones, which are chemicals that control functions in the body. One of the hormones that the ovaries make is estrogen—sometimes called the "female hormone" because women's bodies make more of it than men's bodies do. The ovaries also make androgens—sometimes called "male hormones" because men's bodies make more of them than women's bodies do. Men and women need certain levels of both hormones for normal health.

In women with PCOS, the hormones are out of balance: these women have higher-than-normal levels of androgens and may have lower-than-normal levels of estrogen. High levels of androgens can:

  • Interfere with signals from the brain that normally result in ovulation, so that ovulation does not occur regularly
  • Cause the follicles—small, fluid-filled cysts within the ovaries in which eggs grow and mature—to enlarge, forming cysts2
  • Produce other symptoms of PCOS, including excess hair growth and acne3,4

Other symptoms of PCOS result from problems with insulin, another of the body's hormones. Insulin helps move sugar (also called glucose) from the bloodstream into cells to use as energy. When cells don't respond normally to insulin, the level of sugar in the blood rises. In addition, the level of insulin goes up as the body produces more and more of it to try to get glucose into the cells. Too much insulin increases the production of androgens,5 which then cause symptoms of PCOS. High levels of insulin can also increase appetite and lead to weight gain.3 High insulin levels are also linked to a skin condition called acanthosis nigricans, which results in thickened dark, velvety patches of skin.3

Who is at risk for PCOS?1,6

Women are at higher risk for PCOS if they:

  • Have a mother or sister with PCOS
  • Are obese

Citations

  1. Goodarzi, M. O., Dumesic, D. A., Chazenbalk, G., & Azziz, R. (2011). Polycystic ovary syndrome: Etiology, pathogenesis and diagnosis. Nature Reviews Endocrinology, 7(4), 219–231. Retrieved August 26, 2016, from http://www.nature.com/nrendo/journal/v7/n4/full/nrendo.2010.217.html 
  2. National Center for Biotechnology Information, National Library of Medicine, PubMed Health. (n.d.). Polycystic ovary syndrome. Retrieved May 23, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/24582095
  3. American College of Obstetricians and Gynecologists. (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS 
  4. American Society for Reproductive Medicine. (2003). Hirsutism and polycystic ovary syndrome (PCOS): A guide for patients. Birmingham, AL: American Society for Reproductive Medicine.
  5. Ehrmann, D. A. (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12), 1223–1236.
  6. Sirmans, S. M., & Pate, K. A. (2014). Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical Epidemiology, 6, 1–13.

How do health care providers diagnose PCOS?

Health care providers look for three characteristic features of polycystic ovary syndrome (PCOS): absence of ovulation, high levels of androgens, and cysts on the ovaries. Having one or more of these features could lead to a diagnosis of PCOS. If your medical history suggests that you might have PCOS, your health care provider will rule out other conditions that may cause similar symptoms.

Some of these conditions include:

  • Excess hormone production by the adrenal glands, called adrenal hyperplasia (pronounced uh-DREEN-l hahy-per-PLEY-zhuh)
  • Problems with the function of the thyroid gland
  • Excess production of the hormone prolactin by the pituitary gland, called hyperprolactinemia (pronounced hi-per-pro-lak-tuh-NEE-mee-uh).

After ruling out other conditions and before making a diagnosis of PCOS, your health care provider will do the following:1,2

  • Take a full family history. Your health care provider will ask you about your menstrual cycle and any history of infertility. He or she also will ask you whether you have a mother or sister with PCOS or with symptoms like yours, as PCOS tends to run in families.
  • Conduct a complete physical exam. Your health care provider will do a physical exam and look for extra hair growth, acne, and other signs of high levels of the hormone androgen. He or she also will take your blood pressure, measure your waist, and calculate your body mass index, a measure of your body fat based on your height and weight.
  • Take blood samples. Your health care provider will check the levels of androgens, cholesterol, and sugar in your blood.
  • Do a pelvic exam or ultrasound to check your ovaries. During the pelvic exam, your health care provider will insert two fingers into your vagina and press on your belly to feel for cysts on your ovaries. To help see cysts in your ovaries, he or she might recommend an ultrasound, a test that uses sound waves to take a picture of your pelvic area. Your health care provider also will check how thick the lining of your uterus is; if your periods are irregular, the lining of your uterus could be thicker than normal.

Because there is currently no universal definition of PCOS, different expert groups use different criteria to diagnose the condition. However, all the groups look for the following three features:3

  1. Menstrual irregularities, such as light periods or skipped periods, that result from long-term absence of ovulation (the process that releases a mature egg from the ovary)
  2. High levels of androgens that do not result from other causes or conditions, or signs of high androgens, such as excess body or facial hair
  3. Multiple cysts of a specific size on one or both of the ovaries as detected by ultrasound

Your health care provider will use one of three different methods to diagnose PCOS. One method requires only features 1 and 2 above for a PCOS diagnosis; another requires any two of the three features above for a PCOS diagnosis; and the last one requires feature 1, plus one other feature listed above for a PCOS diagnosis.

Citations

  1. American College of Obstetricians and Gynecologists (ACOG). (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS external link
  2. National Center for Biotechnology Information, National Library of Medicine, PubMed Health. (n.d.).Polycystic ovary syndrome. Retrieved May 23, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/24582095
  3. ACOG Committee on Practice Bulletins—Gynecology. (2009; reaffirmed 2015). ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstetrics and Gynecology, 114(4), 936–949. Retrieved August 5, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/19888063

Is there a cure for PCOS?

There is currently no cure for polycystic ovary syndrome (PCOS), and it does not go away on its own.

Even after menopause, women with PCOS often continue to have high levels of androgens as well as insulin resistance. This means that the health risks associated with PCOS are lifelong.1

Citations

  1. Puurunen, J., Piltonen, T., Morin-Papunen, L., Perheentupa, A., Järvelä, I., Ruokonen, A., et al. (2011). Unfavorable hormonal, metabolic, and inflammatory alterations persist after menopause in women with PCOS. Journal of Clinical Endocrinology and Metabolism, 96, 1827–1834.

What are the treatments for PCOS?

Because polycystic ovary syndrome (PCOS) has a broad range of symptoms, health care providers may use a variety of treatments for this condition and its symptoms.

Because PCOS has a broad range of symptoms, health care providers may use a variety of treatments for this condition and its symptoms.1

The treatment(s) your health care provider suggests will depend on:

  • Your symptoms
  • Your other health problems
  • Whether you want to get pregnant

Because some of the common treatments for PCOS symptoms can prevent pregnancy or may harm the fetus during pregnancy, it's important to discuss your fertility goals with your health care provider while discussing treatment options. Be sure you fully understand your treatment options and their effects on pregnancy before deciding on a course of treatment.

You should also discuss the risks of treatments with your health care provider. All treatments have risks, and some of them can be serious. Also, some unhealthy lifestyle factors such as smoking can increase these risks, and thus you should discuss with your health care provider the best way to eliminate these practices.

Citations

  1. Radosh, L. (2009). Drug treatments for polycystic ovary syndrome. American Family Physician, 79, 671–676.

Treatments for Infertility Resulting from PCOS

In most cases, fertility problems in women with polycystic ovary syndrome (PCOS) result from the absence of ovulation (anovulation), but anovulation may not be the only reason for these problems. Before beginning treatment for infertility possibly related to PCOS, be sure that your health care provider rules out other causes.1

Lifestyle changes, such as losing weight, can trigger body changes that facilitate conception in women with PCOS.2,3 Your health care provider may recommend that you try weight loss and other lifestyle changes before trying any medications to see if fertility returns and pregnancy occurs naturally. Research shows that lifestyle changes can help restore ovulation and improve pregnancy rates among women with PCOS.3,4 Research shows that, among obese women with PCOS who experienced menstrual dysfunction, even losing small amounts of weight improved menstrual function and fertility.5

If you have PCOS-related infertility, your health care provider may prescribe one of the following medications to help you get pregnant.

  • This is the most common treatment for infertility in women with PCOS.1 The American College of Obstetricians and Gynecologists (ACOG) recommends that clomiphene should be the primary medication for PCOS patients with infertility.
  • Clomiphene indirectly causes eggs to mature and be released.6
  • Women treated with clomiphene are more likely to have twins or triplets than women who get pregnant naturally. Women who conceive with the aid of clomiphene are slightly more likely to have multiples, most commonly twins.7

  • Although this insulin-sensitizing drug is normally used to treat diabetes, it may also be used as an adjunct to increase or regulate ovulation in women with PCOS.
  • Metformin can be used alone8 or used with clomiphene when clomiphene alone is not successful.2,3
  • Evidence shows that metformin—both alone and in combination with clomiphene—increases ovulation, but it does not increase the rate of pregnancy.9
  • Metformin is not approved by the FDA for treating PCOS-related infertility.

  • This drug transiently slows estrogen production and causes the body to make more follicle-stimulating hormone (FSH), a hormone needed for ovulation.10
  • An NICHD-supported study found that letrozole is more effective than clomiphene in causing ovulation and improving live-birth rates.11
  • Studies of letrozole in animals have shown that it causes birth defects if used during pregnancy, but there have been no studies of this drug in pregnant women.10,12

  • These hormones, given as shots, cause ovulation.
  • This treatment is costly and has a higher risk of multiple pregnancies than does treatment with clomiphene.4
  • Your health care provider may need to use frequent laboratory tests and ultrasound exams to watch how your body responds to this treatment.4

  • This surgery may increase the chance of ovulation13 and may be considered if lifestyle changes and medications have been used without success.
  • It is unclear whether this treatment is more effective than medications for treating PCOS infertility. The treatment is not recommended by all professional societies.
  • In ovarian drilling, the surgeon makes a small cut in your abdomen and inserts a long, thin tool called a laparoscope (pronounced LAP-er-uh-skohp). The surgeon then uses a needle with electric current to puncture and destroy a small part of the ovary. The surgery leads to lower androgen levels, which may improve ovulation.
  • This surgery may be less costly than treatment with gonadotropin,14 and it does not seem to increase the risk of multiple pregnancies.15 However, it does carry the risk of scarring the ovaries.8

If you do not get pregnant with the treatments listed above, your health care provider may suggest in vitro fertilization, or IVF.16 In this procedure, sperm and an egg are placed in a dish outside the body, in which fertilization occurs. Then a doctor places the fertilized egg into the uterus. IVF may offer women with PCOS the best chance of getting pregnant, and it may give health care providers better control over the risk of multiple births. But it can be expensive and may not be covered by health care insurance.12

Citations

  1. American Society for Reproductive Medicine. (n.d.). Frequently asked questions about infertility.Retrieved May 23, 2016, from https://www.reproductivefacts.org/faqs/frequently-asked-questions-about-infertility/ External Web Site Policy
  2. American College of Obstetricians and Gynecologists.2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS External Web Site Policy
  3. Moran, L. J., Pasquali, R., Teede, H. J., Hoeger, K.M., & Norman, R. J. (2009). Treatment of obesity in polycystic ovary syndrome: A position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertility and Sterility, 92(6), 1966–1982.
  4. Legro, R. S. (2007). Pregnancy considerations in women with polycystic ovary syndrome. Clinical Obstetrics and Gynecology, 50(1), 295–304.
  5. ACOG Committee on Practice Bulletins--Gynecology. (2009). ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstetrics and gynecology, Oct; 114(4):936-49. Retrieved May 16, 2018 from https://www.ncbi.nlm.nih.gov/pubmed/19888063
  6. National Cancer Institute. (2012). Oral contraceptives and cancer risk: Questions and answers. Retrieved May 23, 2016, from http://www.cancer.gov/cancertopics/factsheet/Risk/oral-contraceptives#3
  7. Goodarzi, M. O., Dumesic, D. A., Chazenbalk, G., & Azziz, R. (2011). Polycystic ovary syndrome: Etiology, pathogenesis and diagnosis. Nature Reviews Endocrinology, 7(4), 219–231. Retrieved August 26, 2016, from http://www.nature.com/nrendo/journal/v7/n4/full/nrendo.2010.217.htmlExternal Web Site Policy
  8. Johnson, N. (2011). Metformin is a reasonable first-line treatment option for non-obese women with infertility related to anovulatory polycystic ovary syndrome—A meta-analysis of randomised trials. Australian and New Zealand Journal of Obstetrics & Gynaecology, 51(2), 125–129.
  9. Vause, T. D., Cheung, A. P., Sierra, S., Claman, P., Graham, J., Guillemin, J. A., et al.; Society of Obstetricians and Gynecologists of Canada. (2010). Ovulation induction in polycystic ovary syndrome. Journal of Obstetrics and Gynaecology Canada, 32(5), 495–502.
  10. U.S. Food and Drug Administration (FDA). (2000). VANIQA™ (eflornithine hydrochloride) cream, 13.9%.Retrieved May 23, 2016, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2000/21145lbl.pdf (PDF - 133 KB)
  11. Legro, R. S., Brzyski, R. G., Diamond, M.P., Coutifaris, C., Schlaff, W. D., Casson, P., et al; NICHD Reproductive Medicine Network. (2015). Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. New England Journal of Medicine, 371(2),119–129. Retrieved August 1, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4175743
  12. FDA. (2010). Femara (letrozole) tablets: Highlights of prescribing information. Retrieved May 23, 2016, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020726s019lbl.pdf (PDF - 456 KB)
  13. American Society for Reproductive Medicine.(2014). Ovarian drilling for infertility. Retrieved May 23, 2016, from https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/ovarian-drilling-for-infertility/ External Web Site Policy
  14. Flyckt, R. L., & Goldberg, J. M. (2011).Laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome. Seminars in Reproductive Medicine, 29(2), 138–146.
  15. Fernandez, H., Morin-Surruca, M., Torre, A., Faivre,E., Deffieux, X., & Gervaise, A. (2011). Ovarian drilling for surgical treatment of polycystic ovarian syndrome: A comprehensive review. Reproductive Biomedicine Online, 22(6), 556–568.
  16. American Society for Reproductive Medicine. (2015). Assisted reproductive technologies: A guide for patients. Retrieved May 23, 2016, from https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/assisted-reproductive-technologies-booklet/ External Web Site Policy

Treatments to Relieve Symptoms of PCOS

Treatments for Infertility Resulting from PCOS

 

Treatments to Relieve Symptoms of PCOS

In many cases, the first action that health care providers recommend for women with polycystic ovary syndrome (PCOS) is that they make specific lifestyle changes.

Ways to relieve PCOS symptoms

In many cases, the first action that health care providers recommend for women with PCOS is that they make specific lifestyle changes, such as following a lower-calorie diet, losing weight, and getting more physical activity.1,2

Losing weight and being more physically active can minimize many PCOS symptoms and related conditions. Even a 5% weight loss can improve many symptoms of PCOS.3

A recent NICHD-funded study found that a diet low in dairy and carbohydrates helped women with PCOS lose weight, reduce excess testosterone, and improve insulin sensitivity.8 Talk to your health care provider about designing a plan that's best for you.

  • Weight loss can restore ovulation and make your menstrual cycles more normal, which can improve your chances of pregnancy.1,4
  • Losing weight reduces the risk of diabetes and lowers cholesterol levels.1,5
  • For many women, weight loss reduces such symptoms as excessive hair growth and acne.1,6
  • Physical activity can reduce depression associated with PCOS.7

Also called birth control pills or "the Pill," hormonal contraceptives can be used for the long-term treatment of women with PCOS who do not wish to become pregnant,1 and in fact they are the primary treatment for these women. Oral contraceptive pills contain a combination of the hormones estrogen and progestin. In women with PCOS, these hormones:1

  • Make menstrual periods more regular
  • Reduce the level of androgens produced by the ovaries, leading to reduction in androgen activity
  • Help clear acne and reduce excess hair growth

Oral contraceptives can help lower the risk of certain types of cancers, but they may also raise the risk of other types of cancers.9 There is no one oral contraceptive that works best for women with PCOS, but those that are less androgenic are more effective at treating the symptoms of PCOS.10 Please note that oral contraceptives, like all medications, are associated with some level of risk for side effects, some of them serious. Discuss all possible risks and side effects with your health care provider before making a final decision on a treatment.

These types of medications make the body more responsive to insulin and keep glucose levels more stable.1,11 In women with PCOS, these medications can help:

  • Clear acne and reduce hair growth
  • Improve weight loss
  • Lower cholesterol levels
  • Make periods more regular
  • Slightly reduce infertility associated with PCOS12

After 4 to 6 months of using these medications, women with PCOS may start ovulating naturally.13

The U.S. Food and Drug Administration (FDA) has not approved insulin-sensitizing medications, such as metformin (pronounced met-FAWR-min), specifically for treating PCOS. Even so, your health care provider may use these medications to treat your symptoms. Talk to your health care provider about any concerns you may have about these medications.14

These medications either prevent the body from making androgens or limit the activities or effects of those hormones. In women with PCOS, anti-androgens can:

  • Lower androgen levels
  • Reduce excess hair growth
  • Help clear acne

Because anti-androgens can cause birth defects, they are often taken with oral contraceptives to prevent pregnancy.15 Be sure to talk with your health care provider about the risks of these treatments, especially if you want to become pregnant.

As with insulin-sensitizing medications, anti-androgens are not approved by the FDA for the treatment of PCOS. At this time the best type of anti-androgen for treating PCOS symptoms is not known.

There are many ways to remove excess or unwanted hair or to hide this hair without actually removing it. Women with PCOS can use the methods below instead of or in combination with other approaches:14

  • Daily application of an eflornithine (pronounced ee-FLOOR-nih-theen) cream slows hair growth, especially on the face. This drug works by blocking an enzyme that is needed by hair to grow. If you stop using the cream, the hair will grow back, and so you should talk to your health care provider about a long-term management plan.
    • Eflornithine is FDA-approved for the treatment of unwanted facial hair, but no studies have been published about its use specifically in women with PCOS.14
    • This cream should not be used in pregnant women, and thus you should talk to your health care provider about its risks and benefits before using it, especially if you want to get pregnant.16
  • Shaving, bleaching, plucking, waxing, and using depilatories (creams that dissolve hair, pronounced dih-PIL-uh-tawr-ees) are some of the more common ways of removing or hiding unwanted hair. Some of these methods, such as shaving and plucking, are associated with skin irritation and the development of ingrown hairs.
  • Electrolysis (pronounced ih-lek-TROL-uh-sis), laser hair removal, and intense pulsed light (IPL) therapy are other options, but they are often expensive and may require multiple treatments.1 Electrolysis uses an electric current applied to each hair follicle to destroy its root. Laser hair removal involves shooting a laser beam at each hair follicle to destroy its root. IPL therapy uses an intense flash of light in a specific wavelength that targets the melanin, or color, in hair to effectively kill the hair follicle.

Retinoids (pronounced RET-n-oids), antibacterial agents, and antibiotics may be used to treat acne. These products may be available in pills, creams, or gels. The specific treatment depends on the severity of the acne and how long it has been visible. Because retinoids can cause birth defects, you should not use them if you want to become pregnant.1

Citations

  1. American College of Obstetricians and Gynecologists(ACOG). (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOSExternal Web Site Policy
  2. Moran, L. J., Pasquali, R., Teede, H. J., Hoeger, K. M., & Norman, R. J. (2009). Treatment of obesity in polycystic ovary syndrome: A position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertility and Sterility, 92(6), 1966–1982.
  3. ACOG. (2009; reaffirmed 2015). Polycystic ovary syndrome. Practice Bulletin 108. Washington, DC: ACOG.
  4. Badawy, A., & Elnashar, A. (2011). Treatment options for polycystic ovary syndrome. International Journal of Women's Health, 3, 25–35.
  5. National Heart, Lung, and Blood Institute. (n.d.). Aim for a healthy weight. Retrieved May 23, 2016, from https://www.nhlbi.nih.gov/health-topics/publications-and-resources
  6. Moran, L. J., Hutchison, S. K., Norman, R. J., & Teede, H. J. (2011). Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database of Systematic Reviews, 2, CD007506.
  7. Lamb, J. D., Johnstone, E. B., Rousseau, J. A., Jones, C.L., Pasch, L. A., Cedars, M. I., et al. (2011). Physical activity in women with polycystic ovary syndrome: Prevalence, predictors, and positive health associations. American Journal of Obstetrics and Gynecology, 204(4), 352.e1–352.e6.
  8. Phy, J. L., Pohlmeier, A. M., Cooper, J. A., Watkins, P., Spallholz, J., Harris, K. S., et al. (2015). Low starch/low dairy diet results in successful treatment of obesity and co-morbidities linked to polycystic ovary syndrome (PCOS). Journal of Obesity and Weight Loss Therapy, 5(2), 259.
  9. National Cancer Institute. (2012). Oral contraceptives and cancer risk: Questions and answers. Retrieved May 23, 2016, from http://www.cancer.gov/cancertopics/factsheet/Risk/oral-contraceptives
  10. Mathur, R., Levin, O., & Azziz, R. (2008). Use of ethinylestradiol/drospirenone combination in patients with the polycystic ovary syndrome. Journal of Therapeutics and Clinical Risk Management, 4(2), 487–492.
  11. National Center for Biotechnology Information, National Library of Medicine, PubMed Health. (n.d.). Polycystic ovary syndrome. Retrieved May 23, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/24582095
  12. Legro, R. S., Barnhart, H. X., Schlaff, W. D., Carr, B. R., Diamond, M. P., Carson, S. A., et al. (2007). Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. New England Journal of Medicine, 356(6), 551–566.
  13. Barbieri, R. L. (2003). Metformin for the treatment of polycystic ovary syndrome. Obstetrics and Gynecology, 101(4), 785–793.
  14. Radosh, L. (2009). Drug treatments for polycystic ovary syndrome. American Family Physician, 79(8), 671–676.
  15. Martin, K. A., Chang, R. J., Ehrmann, D. A., Ibanez, L., Lobo, R. A., Rosenfield, R. L., et al. (2008). Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism, 93(4), 1105–1120.
  16. U.S. Food and Drug Administration. (2000). VANIQA™ (eflornithine hydrochloride) cream, 13.9%. Retrieved May 23, 2016, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2000/21145lbl.pdf (PDF - 133 KB)

Treatments to Relieve Symptoms of PCOS

Treatments for Infertility Resulting from PCOS

 

NICHD PCOS Research Goals

NICHD conducts and supports a wide range of research activities to learn more about the causes of polycystic ovary syndrome (PCOS), its risk factors, and its possible treatments.

  • Genetics of PCOS. A number of gene variants have been linked to PCOS and its associated conditions. Ongoing NICHD research projects aim to identify genetic variations that underlie the development of PCOS as well as individual responses to PCOS treatments. These projects include genome-wide association studies as well as studies focused on specific gene variations.
  • Pathophysiological mechanisms of PCOS. PCOS is characterized by hyperandrogenism (high levels of androgens) and, in the majority of cases, insulin resistance. NICHD is working to understand the cellular and molecular mechanisms of ovarian dysfunction in the context of these hormonal abnormalities. Specifically, NICHD aims to characterize the roles of insulin, androgens, and other hormones in reproductive and metabolic dysfunction. The NICHD studies are using both animal models and human participants.
  • Precursors or predictors of PCOS in adolescents. PCOS may be detectable in girls as early as, or even before, their first menstrual periods. Studies are examining early signs of PCOS in adolescents to better understand the relationships among obesity, high androgen levels, and PCOS. This knowledge could help scientists develop early interventions to manage or slow the development of PCOS.
  • New treatment strategies for PCOS. NICHD is evaluating the efficacy of both existing and new treatments for PCOS. These studies include pharmacological (drug) and non-pharmacological treatments. In vitro studies are examining the cellular and molecular mechanisms of pharmacological treatments.

PCOS Research Activities and Advances

Through its intramural and extramural organizational units, NICHD supports and conducts a broad range of research on polycystic ovary syndrome (PCOS). Short descriptions of this research are included below.

The Institute's research focuses on genetic, molecular, and cellular mechanisms underlying PCOS as well as studies to determine precursors or predictors of PCOS in adolescents. NICHD also supports and conducts studies on potential new treatments for PCOS, using animal models and human participants.

The Fertility & Infertility (FI) Branch is NICHD's principal entity for the support of research on PCOS. One of the long-term goals of the FI Branch is to find more effective treatments for the symptoms of PCOS as well as other conditions associated with the disorder. Treatments of interest include both pharmacological and non-pharmacological interventions. The FI Branch is also interested in how individual factors like genetics affect responses to treatment. Other research includes demographic and risk information related to PCOS. Some FI Branch–supported findings include:

  • A New Animal Model to Study PCOS
    PCOS is a complex disease, and until recently, animal models of PCOS were not optimal, because they did not replicate all of the features seen in women with PCOS. NICHD-funded researchers showed that mice treated with the drug letrozole for 5 weeks at the time of puberty go on to develop both the reproductive and metabolic symptoms of PCOS. This new model could prove useful in studying the genetic mechanisms that contribute to PCOS in women and in developing new interventions to treat the disorder. (PMID: 26203175)
  • Treatment for Anovulatory Infertility in PCOS
    The FI Branch's Reproductive Medicine Network conducted a clinical trial to compare the use of clomiphene citrate and letrozole to treat infertility in women with PCOS. The drugs work differently: Clomiphene changes the function of estrogen receptors, whereas letrozole inhibits the enzyme aromatase, which converts androgens to estrogens. The findings indicate that women with PCOS who took letrozole over five menstrual cycles were more likely to ovulate and had 44% more live births than did women who took clomiphene. Letrozole was also just as safe to mothers and babies as clomiphene was. (PMID: 25006718 or see the press release)
  • Urine Levels of Gene Causing High Androgens Could Identify PCOS Women
    By comparing the genomes of thousands of women, researchers compiled a list of candidate genes that could cause PCOS. NICHD-funded researchers found that an unusual product of one of these candidate genes, called DENND1A.V2, alters the synthesis of androgens by the ovaries. Reducing the level of DENND1A.V2 in the steroid-producing cells of the ovaries, the thecal cells, in women with PCOS reduced the production of androgens; forcing overexpression of DENND1A.V2 in normal thecal cells caused them to make too much androgen, just like in PCOS. In addition, levels of DENND1A.V2 are high in the urine of women in PCOS, providing hope that a simple urine test could diagnose PCOS in the future.
    (PMID: 24706793 or see the press release)

The Division of Intramural Research (DIR) also conducts research to advance understanding of the causes of PCOS. For example, a recent finding from researchers in the Section on Genetics and Endocrinology found that a subgroup of women who were diagnosed with PCOS may actually have an adrenal gland disorder instead. Visit https://www.nichd.nih.gov/news/
releases/Pages/062716-PCOS-adrenal.aspx
for more information.

  • The Reproductive Medicine Network (RMN), founded in 1990, carries out large, multicenter clinical trials of diagnostic and therapeutic interventions for male and female infertility and reproductive diseases and disorders. The RMN, which is funded through the FI Branch, conducted several of the studies described above.
  • The Reproductive Genomics Program: Mouse Models of Infertility External Web Site Policy is an NICHD-funded program at the Jackson Laboratory that uses ENU mutagenesis to produce mouse models of infertility and includes mutagenesis of the mouse genome, phenotypic screening for infertility mutations, and regional mapping of each mutation to a chromosome. Breeding stock is available for scientists interested in using these models in their own research programs.
  • The National Centers for Translational Research in Reproduction and Infertility (NCTRI) (formerly the Specialized Cooperative Centers Program in Reproduction and Infertility Research [SCCPIR]) is a national network of research-based centers, supported by the FI Branch, that aims to promote interactions between basic and clinical scientists with the goal of improving reproductive health. Several of the centers focus on diseases and disorders of the female reproductive system, including PCOS.
  • The Ovarian Kaleidoscope Database External Web Site Policy, maintained through the NCTRI, provides information about the biological function, expression pattern, and regulation of genes expressed in the ovary. The database also contains information on gene sequences, chromosomal localization, and human and rodent mutation phenotypes as well as links to biomedical publications.

Are there disorders or conditions associated with PCOS?

Women with polycystic ovary syndrome (PCOS) are at higher risk for several other health conditions, some of them serious.

Insulin is a hormone that helps move sugar (glucose) from the bloodstream into cells to use as energy. Glucose in the blood is the body's main source of fuel. When cells don't respond to insulin, the level of glucose in the blood rises. In addition, the level of insulin goes up as the body produces more and more of it to try to get glucose into the cells.

High levels of insulin can increase appetite and lead to weight gain.1 In addition:

  • Too much glucose and insulin in the blood can lead to serious health conditions, including metabolic syndrome and type 2 diabetes.
  • A symptom of PCOS called acanthosis nigricans (pronounced ay-kan-THOE-sis NY-grih-kanz)—patches of thickened, dark, velvety skin—is associated with insulin resistance.1
  • Too much insulin increases the production of androgens by the ovaries.2 Having abnormally high androgens causes many of the symptoms of PCOS.
  • More than one-half of women with PCOS have insulin resistance.3

This syndrome occurs when the body is not able to balance all the chemicals and processes it needs to create and use energy. Its features include insulin resistance, high blood sugar, obesity, high cholesterol, and high blood pressure.

In people with diabetes, the body has stopped producing insulin or does not use it properly. As a result, the glucose level in the blood rises, but the cells don't get the glucose they need for energy. If the blood glucose level is high for prolonged periods of time or on a regular basis, the condition is called diabetes.

  • If not managed, diabetes can cause serious damage to the kidneys and can lead to blindness, nerve damage, and hearing loss.4
  • Type 2 diabetes also increases the risk for heart disease and high blood pressure.
  • More than one-half of women with PCOS will have either type 2 diabetes or prediabetes (impaired glucose tolerance) before their early 40s.5

Obesity is a condition in which the body stores more fat than is healthy based on a person's height and body type. Obesity in women with PCOS may result from imbalanced hormone levels, increased deposition of fat due to higher insulin levels, metabolic dysfunction (problems with how the body stores and uses energy), or a combination of these factors.

  • Obesity can lead to serious health problems, including diabetes, heart disease, and high blood pressure.
  • The majority of women with PCOS are obese.1

Cardiovascular disease includes a range of different conditions:

  • Coronary artery disease
    • This is a narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart.
    • Coronary artery disease can lead to heart attack, heart failure, or an irregular heartbeat, also called an arrhythmia (pronounced uh-RITH-mee-uh).6
  • Atherosclerosis (pronounced ath-uh-roh-skluh-ROH-sis), or hardening of the arteries
    • Women with PCOS have high levels of low-density lipoprotein (LDL), sometimes called "bad" cholesterol, and low levels of high-density lipoprotein (HDL), sometimes called "good" cholesterol. Both problems are linked to atherosclerosis.2
  • High blood pressure
    • Women with PCOS are at increased risk for high blood pressure.7
    • High blood pressure can increase the risk of stroke. During a stroke, the blood vessels that carry blood to the brain are blocked or broken open so that oxygen and other essential factors are not delivered to the brain cells. Stroke can cause serious disability and even death.8
  • Cardiomyopathy (pronounced kahr-dee-oh-mahy-OP-uh-thee)
    • With this condition, the heart muscle becomes larger, thick, and hard, making the heart less able to pump blood to the body.9

Several factors related to PCOS, including insulin resistance, metabolic syndrome, and obesity, increase a woman's risk of cardiovascular disease.1

Heart disease is the leading killer of women in the United States,5 and several studies have found that women with PCOS are at increased risk for cardiovascular disease.10 Doctors should regularly screen PCOS patients for their risk of heart disease.11

Obstructive (pronounced uhb-STRUHKT-ihv) sleep apnea (pronounced AP-nee-uh) occurs when a person's airway becomes too narrow during sleep. When people sleep, the muscles that keep the airway open relax. In some people, the relaxed muscles allow the airway to narrow or close for a short time. As a result, breathing stops for several seconds. Often, when the person starts breathing again, he or she makes a snorting or choking sound.

  • Sleep apnea increases the risk of high blood pressure, heart attack, obesity, and diabetes.12
  • Women with PCOS are at much higher risk for obstructive sleep apnea than are other women.13 This risk is even higher among women with PCOS who are obese.

Women with PCOS are more likely to have mood disorders, such as depression or anxiety, or to engage in out-of-control (or binge) eating. Certain features of PCOS may contribute to the increased risk of mood disorders. For example:

  • Abnormal levels of androgens and other hormones are related to mood disorders.2
  • Obesity is linked to mood disorders as well as to abnormal hormone levels. Studies show that the risk of mood disorders is even greater among women with PCOS who are also obese.2,14

Inflammation is the body's normal protective response to infection or injury. However, inflammation is also involved in several dangerous conditions, such as hardened arteries, which are a major risk factor for heart attack and stroke. Some evidence suggests that women with PCOS experience long-term, low-level inflammation.

Currently, it's not clear whether this inflammation results from obesity and metabolic dysfunction, which are also common among women with PCOS, or whether it is an independent symptom of the disorder. It's also not clear whether chronic, low-level inflammation might have long-term health consequences for women with PCOS. Ongoing research on these questions should help to clarify the role of inflammation in PCOS.15

Citations

  1. American College of Obstetricians and Gynecologists (ACOG). (2015). Polycystic ovary syndrome. Retrieved May 20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS external link
  2. Ehrmann, D. A. (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12), 1223–1236.
  3. Goodarzi, M. O., Dumesic, D. A., Chazenbalk, G., & Azziz, R. (2011). Polycystic ovary syndrome: Etiology, pathogenesis and diagnosis. Nature Reviews Endocrinology, 7(4), 219–231. Retrieved August 26, 2016, from http://www.nature.com/nrendo/journal/v7/n4/full/nrendo.2010.217.html external link
  4. American Diabetes Association. (n.d.). Living with diabetes: Complications. Retrieved May 23, 2016, from http://www.diabetes.org/living-with-diabetes/complications external link
  5. Lorenz, L. B., & Wild, R. A. (2007). Polycystic ovarian syndrome: An evidence-based approach to evaluation and management of diabetes and cardiovascular risks for today's clinician. Clinical Obstetrics and Gynecology, 50(1), 226–243.
  6. National Heart, Lung, and Blood Institute (NHLBI). 2015). What is coronary heart disease? Retrieved May 23, 2016, from https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease
  7. Hunter, M. H., & Sterrett, J. J. (2000). Polycystic ovary syndrome: It's not just infertility. American Family Physician, 62(5), 1079–1088, 1090.
  8. NHLBI. (2015). What is a stroke? Retrieved May 23, 2016, from https://www.nhlbi.nih.gov/health-topics/stroke
  9. NHLBI. (2015). What is cardiomyopathy? Retrieved May 23, 2016, from https://www.nhlbi.nih.gov/health-topics/cardiomyopathy
  10. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. (2004). Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertility & Sterility, 81(1), 19–25.
  11. ACOG. (2009; reaffirmed 2015). Polycystic ovary syndrome. Practice Bulletin 108. Washington, DC: ACOG.
  12. NHLBI. (2012). What is sleep apnea? Retrieved May 23, 2016, from http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea
  13. Fogel, R. B., Malhotra, A., Pillar, G., Pittman, S. D., Dunaif, A., & White, D. P. (2001). Increased prevalence of obstructive sleep apnea syndrome in obese women with polycystic ovary syndrome. Journal of Clinical Endocrinology and Metabolism, 86(3), 1175–1180.
  14. Barry, J. A., Kuczmierczyk, A. R., & Hardiman, P. J. (2011). Anxiety and depression in polycystic ovary syndrome: A systematic review and meta-analysis. Human Reproduction, 26(9), 2442–2451.
  15. Duleba, A. J., & Dokras A. (2012). Is PCOS an inflammatory process? Fertility & Sterility, 97(1), 7–12. Retrieved August 26, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3245829/

Can PCOS lead to cancer?

PCOS increases the risk of some types of cancer.

For instance, some research has shown that risk of cancer of the endometrium (pronounced en-doh-MEE-tree-uhm), the inside lining of the uterus, may be higher for women with polycystic ovary syndrome (PCOS) than it is for women without PCOS.1 Irregular periods, or a lack of periods, can cause the endometrium to build up and become thick. This thickening can lead to endometrial cancer.2,3,4

Data on links between breast cancer, ovarian cancer, and PCOS are limited. While some small studies have suggested that a lack of ovulation, as occurs with PCOS, is linked with an increased risk of breast cancer, other studies have not shown an association.1 While some research has shown more than a doubling of the risk of ovarian cancer in women with PCOS,5 scientists have not confirmed these links in large population studies, and further studies hint that women with PCOS may have a lower risk of ovarian cancer.1,2,6 Therefore, any associations between breast or ovarian cancers and PCOS remain inconclusive.

Learn more about these different types of cancers on the National Cancer Institute website:

Citations

  1. Daniilidis, A., & Dinas, K. (2009). Long term health consequences of polycystic ovarian syndrome: A review analysis. Hippokratia, 13(2), 90–92.
  2. Ehrmann, D. A. (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12), 1223–1236.
  3. American Society for Reproductive Medicine. (2014). Patient fact sheet: Polycystic ovary syndrome. Retrieved May 23, 2016, from https://www.asrm.org/topics/topics-index/polycystic-ovary-syndrome-pcos/ external link
  4. National Center for Biotechnology Information, National Library of Medicine, PubMed Health. (n.d.). Polycystic ovary syndrome. Retrieved May 23, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/24582095
  5. Schildkraut, J. M., Schwingl, P. J., Bastos, E., Evanoff, A., & Hughes, C. (1996). Epithelial ovarian cancer risk among women with polycystic ovary syndrome. Obstetrics and Gynecology, 88(4 Pt 1), 554–559.
  6. Barry, J. A., Kuczmierczyk, A. R., & Hardiman, P. J. (2011). Anxiety and depression in polycystic ovary syndrome: A systematic review and meta-analysis. Human Reproduction, 26(9), 2442–2451.

If I have PCOS, will I be able to get pregnant?

Even though polycystic ovary syndrome (PCOS) is a leading cause of infertility in women, PCOS-related infertility is treatable in most cases. Women with PCOS can and do still get pregnant—sometimes naturally, sometimes with help.

Visit the Treatments for Infertility Resulting from PCOS section for more information about treatments that help women with PCOS get pregnant.

Does PCOS affect pregnancy?

Women with polycystic ovary syndrome (PCOS) are at higher risk for certain problems or complications during pregnancy. In addition, infants born to mothers with PCOS are at higher risk of spending time in the neonatal intensive care unit or dying before, during, or right after birth. Complications of pregnancy commonly associated with PCOS could be a reason for these risks. Also, conditions common to PCOS like metabolic syndrome and increased androgens may increase the risks affecting infants.1,2

Pregnancy complications related to PCOS include:

  • Miscarriage or early loss of pregnancy. Women with PCOS are three times as likely to miscarry in the early months of pregnancy as are women without PCOS.2,3 Some research shows that metformin may reduce the risk of miscarriage in pregnant women with PCOS. However, other studies have not confirmed that metformin reduces miscarriage risk, so more research needs to be done.2,4,5
  • Gestational (pronounced je-STEY-shuhn-uhl) diabetes. This is a type of diabetes that only pregnant women get. It is treatable and, if controlled, does not cause significant problems for the mother or fetus. In most cases, the condition goes away after the baby is born. Babies whose mothers have gestational diabetes can be very large (resulting in the need for cesarean, or C-section [surgical], delivery), have low blood sugar, and have trouble breathing. Women with gestational diabetes, as well as their children, are at higher risk for type 2 diabetes later in life.
  • Preeclampsia (pronounced pree-i-KLAMP-see-uh). Preeclampsia, a sudden increase in blood pressure after the 20th week of pregnancy, can affect the mother's kidneys, liver, and brain. If left untreated, preeclampsia can turn into eclampsia. Eclampsia can cause organ damage, seizures, and even death. Currently, the primary treatment for the condition is to deliver the baby, even preterm if necessary. Pregnant women with preeclampsia may require a C-section delivery, which can carry additional risks for both mother and baby.5
  • Pregnancy-induced high blood pressure. This condition is due to an increase in blood pressure that may occur in the second half of pregnancy. If not treated, it can lead to preeclampsia. This type of high blood pressure can also affect delivery of the baby.
  • Preterm birth. Infants are considered "preterm" if they are delivered before 37 weeks of pregnancy. Preterm infants are at risk for many health problems, both right after birth and later in life, and some of these problems can be serious.
  • Cesarean or C-section delivery. Pregnant women with PCOS are more likely to have C-sections because of the pregnancy complications associated with PCOS, such as pregnancy-induced high blood pressure.4,6 Because C-section delivery is a surgical procedure, recovery can take longer than recovery from vaginal birth and can carry risks for both the mother and infant.

Researchers are studying whether treatment with insulin-sensitizing drugs such as metformin can prevent or reduce the risk of pregnancy problems in women with PCOS.3,7,8

If you have PCOS and get pregnant, work with your health care provider to promote a healthy pregnancy and delivery.

Citations

  1. Ehrmann, D. A. (2005). Polycystic ovary syndrome. New England Journal of Medicine, 352(12), 1223–1236.
  2. Boomsma, C. M., Fauser, B. C., & Macklon, N. S. (2008). Pregnancy complications in women with polycystic ovary syndrome. Seminars in Reproductive Medicine, 26(1), 72−84.
  3. Jakubowicz, D. J., Iuorno, M. J., Jakubowicz, S., Roberts, K. A., & Nestler, J. E. (2002). Effects of metformin on early pregnancy loss in the polycystic ovary syndrome. Journal of Clinical Endocrinology and Metabolism, 87(2), 524–529.
  4. Morin-Papunen, L., Rantala, A. S., Unkila-Kallio, L., Tiitinen, A., Hippeläinen, M., Perheentupa, A., et al. (2012). Metformin improves pregnancy and live-birth rates in women with polycystic ovary syndrome (PCOS): A multicenter, double-blind, placebo-controlled randomized trial. Journal of Clinical Endocrinology and Metabolism, 97(5), 1492–1500.
  5. American College of Obstetricians and Gynecologists. (2014). Preeclampsia and high blood pressure during pregnancy. Retrieved May 23, 2016, from https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancyexternal link 
  6. Schildkraut, J. M., Schwingl, P. J., Bastos, E., Evanoff, A., & Hughes, C. (1996). Epithelial ovarian cancer risk among women with polycystic ovary syndrome. Obstetrics and Gynecology, 88(4 Pt 1), 554–559.
  7. Begum, M. R., Khanam, N. N., Quadir, E., Ferdous, J., Begum, M. S., Khan, F., et al. (2009). Prevention of gestational diabetes mellitus by continuing metformin therapy throughout pregnancy in women with polycystic ovary syndrome. Journal of Obstetrics and Gynaecology Research, 35(2), 282–286.
  8. Vanky, E., Stridsklev, S., Heimstad, R., Romundstad, P., Skogøy, K., Kleggetveit, O., et al. (2010). Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: A randomized, controlled multicenter study. Journal of Clinical Endocrinology and Metabolism, 95(12), E448–E455.
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