Polycystic ovary syndrome (PCOS) : Information

Introduction : Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is one of the most common hormonal disorders among women of reproductive age. PCOS is common diagnosis in women presenting with infertility. The exact prevalence of PCOS is not known as the syndrome is not defined precisely. Prevalence of PCOS is highly variable ranging from 2.2% to 26% globally. In few Asian countries prevalence figures are ranging from 2% to 7.5% in China and 6.3% in Srilanka. There are few studies conducted in India. Studies done in South India and Maharashtra, prevalence of PCOS (by Rotterdam's criteria) were reported as 9.13% and 22.5% (10.7% by Androgen Excess Society criteria) respectively.

PCOS was first reported by Stein and Leventhal in 1935, described as symptoms complex with amenorrhea, hirsutism, and enlarged ovaries with multiple cysts.

Polycystic ovary syndrome causes irregular menstrual cycles, excessive body or facial hair and polycystic ovaries as its main symptoms. Polycystic means "many cysts," and PCOS often causes clusters of small, pearl-sized cysts in the ovaries. The cysts are fluid-filled and contain immature eggs. Women with PCOS produce slightly higher amounts of male hormones known as androgens, which contribute to some of the symptoms of the condition.

Early diagnosis of PCOS is important as it has been linked to an increased risk for developing several medical conditions including insulin resistance, type 2 diabetes, high cholesterol, high blood pressure and heart disease. PCOS is an emerging health problem during adolescence therefore promotion of healthy lifestyles and early interventions are required to prevent future morbidities.







Symptoms : Polycystic ovary syndrome (PCOS)

PCOS is a syndrome disease defined by a group of signs (physical findings) and symptoms (patient complaints).Symptoms can vary from woman to woman. Some of the symptoms of PCOS include:

  • Infertility (not able to get pregnant) - PCOS is the most common cause of female infertility. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned. In addition, the rate of miscarriage is also higher in affected women.
  • Infrequent, absent, and/or irregular menstrual periods- The menstrual irregularities in PCOS usually present around the time of menarche.
  • Hirsutism -increased hair growth on the face, chest, back, thumbs, or toes
  • Acne, oily skin, or dandruff
  • Weight gain or obesity, usually with extra weight around the waist
  • Male-pattern baldness or thinning hair
  • Patches of skin on the neck, arms, breasts, or thighs that are thick and dark brown or black
  • Skin tags(excess flaps of skin in the armpits or neck area)
  • Pelvic pain
  • Anxiety or depression
  • Sleep apnea (when breathing stops for short periods of time while asleep)
  • Cysts in the ovaries




Causes : Polycystic ovary syndrome (PCOS)

The cause of PCOS is unknown. But most experts think that several factors, including genetics, could play a role. Women with PCOS are more likely to have a mother or sister with PCOS.

A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. Androgens are male hormones that females also make. High levels of these hormones affect the development and release of eggs from ovary each month (process called ovulation).

Researchers also think insulin may be linked to PCOS. Insulin is a hormone that controls the change of sugar, starches, and other food into energy for the body to use or store. Many women with PCOS have too much insulin in their bodies because they have problems using it. Excess insulin appears to increase production of androgen.

High androgen levels can lead to:

  • Acne
  • Excessive hair growth
  • Weight gain
  • Problems with ovulation



Diagnosis : Polycystic ovary syndrome (PCOS)

There are different criteria for diagnosis of PCOS

  • Rotterdam criteria (2004) include at least two of the following three conditions: Clinical and/or biochemical hyperandrogenism (androgen excess), oligo-ovulation or anovulation (irregular ovulation or absence of ovulation), and polycystic ovaries (12 or more follicles in at least 1 ovary).

(Exclusion of all other disorders that can result in menstrual irregularity and hyperandrogenism, including adrenal or ovarian tumors, thyroid,dysfunction, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and Cushing syndrome)

  • Androgen Excess Society (AES), 2006 considered PCOS as a primarily disorder of androgen excess or hyperandrogenism and defined PCOS by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction and/or polycystic ovaries, and the exclusion of related disorders.
  • According to American Association of Clinical Endocrinologists (AACE) and the Androgen Excess and PCOS Society (AES) 2015, diagnosis of PCOS is based on presence of at least two of the following three conditions: chronic anovulation (Cycle length >35 days), hyperandrogenism (clinical or biological) and polycystic ovaries..

Tests for evaluation of PCOS:

  • Follicle stimulating hormone (FSH)
  • Lutenizing hormone
  • Testosterone
  • Estrogens
  • Sex hormone binding globulin (SHBG)
  • Androstenedione
  • Human chorionic gonadotropin (HCG)
  • Anti-M llerian hormone

Tests to rule out other conditions with similar signs and symptoms:

  • Thyroid stimulating hormone (TSH) to rule out thyroid dysfunction.
  • Cortisol to rule out Cushing syndrome .
  • Serum Prolactin to rule out elevated prolactin (hyperprolactinemia)
  • 17-hydroxyprogesterone to rule out the most common form of congenital hyperplasia.
  • Serum free insulin like growth factor-1 (IGF-1) to rule out excess growth hormone (acromegaly).
  • Dehydroepiandrosterone Sulfate (DHEAS) to rule out an adrenal tumor

Other blood tests to check a woman's health and detect any complications:

  • Lipid profile-to help determine risk of developing Cardiovascular disease ; risk is associated with a low High density lipoproteins (HDL), high low density lipoproteins (LDL), high total cholesterol and/or elevated triglycerides (Dyslipidemia).
  • Glucose or Hemoglobin A1c (HbA1c) can be used to detect diabetes; elevated in diabetes.
  • Insulin often elevated in insulin resistance.

Imaging tests:

The following imaging studies may be used in the evaluation of PCOS:

  • Ovarian ultrasonography, preferably using transvaginal approach.
  • Pelvic CT scan or MRI to visualize the adrenals and ovaries.





Management : Polycystic ovary syndrome (PCOS)

Treatment of PCOS is not curative. Treatment focuses on controlling symptoms and managing the condition to prevent complications. The treatment will vary from woman to woman, depending on specific symptoms. Life style modifications consisting of a healthy diet and regular exercise are recommended for all women with PCOS, particularly those who are overweight.

Lifestyle modifications: Certain lifestyle changes, such as diet and exercise, are considered first-line treatment for adolescent girls and women with polycystic ovarian syndrome. These modifications have been effective in restoring ovulatory cycles and achieving pregnancy in obese women with PCOS. Weight loss in obese women with PCOS also improves androgen levels. Healthy eating tips include:

  • Limiting processed foods and foods with added sugars, eating a diet low in cholesterol and saturated fats,
  • Adding more whole-grain products, fruits, vegetables, and lean meats to diet.

This helps to lower blood glucose (sugar) levels, improve the body's use of insulin, and normalize hormone levels in the body. Even a 10 percent loss in body weight can restore a regular cycle.

Pharmacologic treatments: are used for metabolic derangements, such as anovulation, hirsutism, and menstrual irregularities:

  • Oral contraceptive agents/ Birth control pills/ are used to regularize menstrual cycle for women who don't want to get pregnant.
  • Fertility medication- Lack of ovulation is usually the reason for fertility problems in women with PCOS. Several medications that stimulate ovulation can help women with PCOS to become pregnant.
  • Clomiphene therapy to stimulate ovulation.
  • Metformin* along with clomiphene -The combination may help to use lower doses of medication to induce ovulation.

(*Metformin (Glucophage) is used to treat type 2 diabetes. It has also been found to help with PCOS symptoms; Metformin controls blood glucose (sugar) and lowers testosterone production. It slows the growth of abnormal hair and, helps in ovulation.)

  • Gonadotropins-Low dose gonadotropin treatment regimens are used in PCOS cases, not responding to clomiphene therapy.
  • Medicine for increased hair growth or extra male hormones- Medicines called anti-androgens may reduce hair growth and clear acne. Anti-androgens are often combined with birth control pills. These medications should not be taken if one is trying for pregnancy.

Surgical management of PCOS is advised in women who do not start ovulation after medical treatment. Various Laparoscopic ovarian surgeries include the following:

  • Electrocautery
  • Laser drilling
  • Multiple biopsy



Prevention : Polycystic ovary syndrome (PCOS)

PCOS cannot be prevented, but early diagnosis and treatment helps to prevent long-term complications, such as infertility, metabolic syndrome, obesity, diabetes and heart disease.

A healthy lifestyle consists of a healthy diet, regular exercise and maintaining a healthy weight is helpful in preventing various complications. Further regular checkups are recommended for early diagnosis of these complications.

Healthy Life style measures-

(a)Eating right-

  • Limiting processed foods and foods with added sugars,
  • Adding more whole-grain products, fruits (whole fruits instead of fruit juice), vegetables (Green leafy and brightly coloured vegetables), and lean meats to diet.
  • Choose carbohydrates that have a low glycemic index. (The glycemic index is a measure of how quickly and how strongly a food increases blood sugar and insulin levels). Choosing foods with a lower glycemic index (whole grain breads, cereals) may help to reduce carbohydrate cravings.
  • Avoid saturated fats (dairy products and red meat) by choosing healthy fats which are found in nuts and seeds, oily fish, avocado.
  • Eat small, healthy meals more frequently to manage cravings and hunger pangs and never miss breakfast.
  • Plant-based protein foods such as beans and nuts and lean proteins are all healthy options for girls with PCOS.

(b) Exercising: It s really important that females with PCOS exercise, because exercise brings down insulin levels, and can help with weight loss.

(c) Not smoking.

(d) Manage stress level.

(e) Share the burden and get good support from family and friends.

Eating well, staying active, and maintaining a healthy weight (or losing even a small amount of weight if you re overweight) can improve PCOS symptoms.




Medical Condition : Polycystic ovary syndrome (PCOS) : Endocrinal