I have no periods: Is it Polycystic ovaries?
Polycystic ovaries are both the simplest and most difficult of my consultations.
What is a normal monthly cycle?
To understand polycystic ovaries it is important to have an understanding of what is normal. Most women have a regular monthly cycle and know when their period is due. This is because they have regular ovulation (or the point where the egg bursts from the ovary).
A 28 or 35 day cycle can both be described as regular. What both cycles have in common is that from ovulation to period is 14 days, so:
- If the cycle is 28 days, ovulation will take place on day 14, but
- If the cycle is 35 days, then ovulation takes place on day 21.
This is very important to understand for timing intercourse.
Ovulation is the controller of the entire cycle. At the start of each cycle, the ovary produces the hormones oestrogen which grows the lining of the womb for an embryo to implant. With Ovulation the second hormone of the ovary, progesterone is released. It is the job of progesterone to stabilise the lining of the uterus for two weeks, until the embryo produces similar hormones.
So, this explains the normal cycle.
What are polycystic ovaries?
I like to describe polycystic ovaries as “resistant” ovaries. They start the process like every other ovary at the beginning of the cycle however one follicle does not take over like normal and become a dominant follicle and ovulate. As a result the pituitary (in the brain) tries to make the ovaries work harder and a large number of follicles try to enlarge.
These follicles, each of which contains an egg, are what are falsely called cysts on ultrasound. They are all producing hormones but as ovulation has not occurred these hormones are diverted to make other hormones, which are mostly androgen, or male type hormones.
The symptoms are irregular or no periods (hence infertility) and some side effects of the alternate hormones like acne and skin flare-ups.
PCOS and infertility
When seeing couples for the first time for infertility where polycystic ovaries may be a factor, we do a few standard things.
A blood test can tell us many reassuring things, from excluding other causes of no periods through to providing a good indication of the long-term life of the ovaries using a test called AMH. The ultrasound is almost diagnostic. If women of childbearing age come with no periods and polycystic ovaries on ultrasound, then this is nearly always the answer.
After reading the internet, many women become very anxious about PCOS. However, this condition is one of the most satisfying to be involved with. Sometimes, simple measures such as losing or gaining some weight or changing an exercise routine may be all that is required. Ovaries are very sensitive to weight, and both overweight and underweight women are definitely more resistant to ovulation.
We have known for a long time the long-term effects of polycystic ovaries. Long-term studies have also shown a relationship between women with polycystic ovaries and late-onset diabetes and abnormal lipids. The reason for bringing this to attention here is a treatment for non-insulin diabetes in the form of a simple tablet called metformin helps a percentage of women to ovulate and can be very effective.
What the next step?
The reason treating PCOS is so rewarding is that if the above conservative options are not successful, then in a stepwise fashion from clomid through to IVF there will be something that works. In saying that, the decision as to treatments is always a very individual one.
If you are not having periods and want to get pregnant my advice is, don’t wait! See your GP or fertility specialist as there are many options to help you start your family.