The Facts about PCOS
Poly cystic ovary syndrome is a primarily a hormonal disorder associated with cysts in the ovary. It is very common in the general population and various studies have shown ithe prevalence at 4-12%. This disease is most commonly seen in the child bearing years and PCOS is never seen after menopause.
Hormonal changes in PCOS
The normal development and ovulation is controlled by two hormones secreted by brain: Follicle stimulating hormone (FSH) and Luteinising hormone (LH). In women with PCOS there is a relative deficiency of the LH compared to FSH. This leads to increased production of androgens (male hormones) by the ovary leading to many of the manifestations of this disease. As a result of this imbalance of androgens and estrogens the ovary is not able to produce any eggs and hence these cycles are called anovulatory cycles.
PCOS is also associated with changes in the body’s handling of glucose. Peripheral tissues become less sensitive to the effect of insulin and hence the pancreas produces more insulin. Excess of insulin is usually present in blood (hyperinsulinemia). This over a period of time leads to development of high blood sugar.Signs and Symptoms
Women with PCOS generally present with the following features:
A. Menstrual abnormalities-Patients have abnormal menstruation patterns attributed to chronic anovulation. Some women have oligomenorrhea (ie, menstrual bleeding that occurs at intervals of 35 d to 6 mo, with <9 menstrual periods per y) or secondary amenorrhea (an absence of menstrual for 6 mo). Dysfunctional uterine bleeding and infertility are the other consequences of anovulatory menstrual cycles. The menstrual irregularities in PCOS usually manifest around the time of menarche (puberty).
B. Effects of excess male hormones (Hyperandrogenism): Hyperandrogenism manifests as excess terminal body hair in a male distribution pattern. Hair is commonly seen on the upper lip, chin, around the nipples, and along the midline of the lower abdomen. Some patients have acne and/or male-pattern hair loss (hair loss around the temples and balding).A few patients may also have increased muscle mass, deepening voice, and/or clitoromegaly(enlargement of clitoris) due to excessive androgens.
C. Infertility: A subset of women with PCOS are infertile. Most women with PCOS ovulate intermittently. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned.
D. Obesity: Obesity is present in nearly half of all women with PCOS.
E. Diabetes: Approximately 10% of women with PCOS have type 2 diabetes mellitus, and 30-40% of women with PCOS have impaired metabolism of glucose by the age of 40 years.
Apart from the above abnormalities, women with PCOS may also suffer from increased prevalence of coronary artery calcification and a thickened carotid intima media, which may be responsible for subclinical atherosclerosis. Numerous patients with PCOS have characteristics of metabolic syndrome. One study showed a 43% prevalence of metabolic syndrome in women with PCOS. Metabolic syndrome is characterized by abdominal obesity (waist circumference > 35 in.), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] level < 50 mg/dL) and elevated blood pressure. Metabolic syndrome has been recognised as a risk factor for heart disease.
Diagnosis
The diagnosis of PCOS must be actively considered in any women of child bearing age who presents with oligimenorrhoea or amenorrhoea along with signs of excess androgens. Diagnosis is most commonly established by ultrasound and presence of ovarian cysts in presence of signs of excess male hormones clinches the diagnosis.
Treatment
Treatment of this condition requires a two pronged approach. We must aim to negate this hormonal imbalance by pharmacologic as well as non pharmacologic measures.
The Androgen Excess and Polycystic Ovary Syndrome Society recommends lifestyle management as the primary therapy in overweight and obese women with PCOS for the treatment of metabolic complications. In patients with PCOS who are obese, endocrine-metabolic parameters markedly improve after 4-12 weeks of dietary restriction. Weight loss in patients with PCOS who are obese is associated with a reduction of hirsutism and a return of ovulatory cycles in 30% of women. PCOS patients who have impaired glucose tolerance should start a comprehensive program of diet and exercise to reduce their risk of developing diabetes mellitus. A diet patterned after the type 2 diabetes diets have been recommended for PCOS patients. This diet emphasizes increased fiber; decreased refined carbohydrates, Trans fats, and saturated fats; and increased omega-3 and omega-9 fatty acids. Omega-3 fatty acid supplementation has been shown to reduce liver fat content and other cardiovascular risk factors in women with PCOS.
Metformin, an anti-diabetic drug improves insulin resistance and decreases hyperinsulinemia in patients with PCOS. Metformin also has a small but beneficial effect on metabolic syndrome. Metformin frequently—but not universally—improves ovulation rates in women with PCOS.
Women who do not wish to become pregnant can be effectively treated for hirsutism with oral contraceptives. Oral contraceptives slow hair growth in 60-100% of women with hyperandrogenemia(excess male hormones).
To conclude, PCOS is a disease with many long-term complications. Patients need regular follow-up with their physicians for early detection and management of any untoward sequelae associated with PCOS.
Surgery for PCOS consists of either wedge resection of the ovary or laparoscopic rupture of these cysts.
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