PCOS/PCOD/Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome or PCOS is a hormonal endocrine disorder of ovary in women in all over the world. Other name for PCOS is Stein-Leventhal Syndrome. As the name indicates multiple cysts in the ovary is called polycystic ovary syndrome, and the size of ovaries in women with PCOS are 2 to 5 times the normal size.
Undiagnosed and untreated PCOD is a leading cause of female infertility. PCOS affects 4 to 6% of women, the full-blown syndrome of hyperandrogenism, chronic anovulation and polycystic ovaries. Because of wide variety of clinical symptoms and biochemical features exact definition of Polycystic Ovary Syndrome is least understood and can be confusing. According to Rotterdam criteria definition of PCOS contains two out of three following criteria:
1. Oligomenorrhea or Anovulation
2. Hyperandrogenism (clinical/biochemical)
3. Polycystic ovaries with exclusion of other etiologies.

Hormonal and biochemical changes are responsible for PCOS symptoms. There may be abnormality in the four active compartments: a) ovary, b) hypothalamus-pituitary compartment, c) peripheral fat or d) adrenal glands. Abnormality in ovarian compartment is responsible for hyperandrogenism in PCOS. Ovaries in women with PCOS are 2 to 5 times the normal size.

Hormonal changes in PCOS
1. Hyperandrogenism – Increased level of total and free testosterone.
High intraovarian androgen concentration inhibits follicle maturation results in inactive granulosa cells with minimal aromatase activity for conversion to estrogens.
2. Increased LH without increase in FSH leads to Increase LH/FSH ratio.

Clinical symptoms

1. Menstrual dysfunction – From amenorrhea to oligo menorrhea. Menarche tends to be delayed, irregular menstrual cycles or 4 to 6 menstrual periods per year.
2. Acne – Severe acne in teenage years is very common finding of PCOS.
3. Obesity – About 50 % women with PCOS found obese. Obesity in PCOS linked to insulin resistance, diabetes mellitus and increased risk of cardiovascular disease in later life.
4. Hirsutism – Excess hair growth on the face and body.
5. Alopecia – Hair loss and male pattern baldness.
6. Acanthosis nigricans – Hyperpigmentation of the skin.
7. InfertilityInfertility is the common problem in PCOS women.

How to Diagnose?

1. Symptoms and clinical features are most important in early diagnosis. Patient gives history of irregular menstruation, acne, excess facial hair growth and weight gain (high BMI). During reproductive age women may have history of infertility.

2. Laboratory tests – Blood tests to know the level of some hormones, Blood sugar, Insulin and IGF 1, cholesterol and triglycerides level in PCOS women.
Criteria for metabolic syndrome in PCOS women
• Abdominal obesity (waist circumference >88 cm or 35 inches)
• Triglycerides >150 mg/dl
• HDL-C <50 mg/dl
• Blood pressure > 130/85
• Fasting blood sugar of 110-126 mg/dl and 2-hour glucose from oral glucose tolerance test of 140-199 mg/dl

3. Ultrasonography – Ultrasonographic examination is a useful method for early detection of PCOS and follow-up. Generally, ovarian size is increased. The most important ultrasonographic finding is a bilaterally increased number of microcysts measuring 0.5 to 0.8 cm with generally more than five microcysts in each ovary.

Management

The management of PCOS depends upon clinical symptoms and presenting problems.

Menstrual irregularities
1. Weight loss – In obese women weight loss should be the first line of treatment. A reduction in body weight of 5-10 per cent will cause a 30 per cent reduction in visceral fat, which is often sufficient to restore ovulation and reduce markers of metabolic disease.
2. Oral contraceptives – Often OCPs can have the benefits of contraception, protection against endometrial cancer and improve skin manifestations such as acne and hirsutism.

Acne
Mild acne can be treated topically with keratinolytics such as azelaic acid, retinoids or with antibacterials erythromycin 2 % gel or clindamycin 1 % lotion. Severe forms can be treated by oral antibiotics or isotretinoin.
But in PCOS antiandrogens are most effective because acne occurs as a result of hyperstimulation of sebaceous glands by androgens. Cyproterone acetate, Spironolactone Flutamide and Finasteride have antiandrogenic properties. Cyperoterone acetate can be combined with OCPs.

Hirsutism
Hirsutism can be treated by physical therapy such as bleaching, shaving, plucking, depilatory creams or electrolysis and laser. Combined Oral contraceptive is useful for prevention of excess hair growth.

Alopecia
Psychological supports and hairstyling are the treatment for alopecia. Drugs such as minoxidil, cyproterone acetate, spironolactone has limited role.

Infertility
Main cause of infertility in PCOS is anovulation. So methods of inducing ovulation are reduction of insulin concentrations, FSH (follicular stimulating hormone) stimulation and reduction in LH (luteinizing hormone) concentration.

Weight loss
Weight loss is the mainstay therapy for induction of ovulation. Weight loss improves endocrine profile and the likelihood of ovulation and a healthy pregnancy. Diet plan and exercises should be encouraged.

Clomiphene citrate
Clomiphene citrate 50 mg orally for 5 days is a common method to induce ovulation. Serial transvaginal ultrasound is used to look for follicles or urinary LH test can also be done to know fertile period.

Metformin
For treating hyperinsulinemia in PCOS women Metformin 500 mg 8 hourly is an effective treatment.
In patients who do not ovulate with clomiphene citrate and metformin, doctor can advise for laparoscopic ovarian drilling or parenteral gonadotrophic therapy.

Laparoscopic ovarian drilling
Laparoscopic ovarian drilling is a simple procedure whereby several punctures are made in one or both the polycystic ovaries.

Gonadotropin therapy
Gonadotrophin therapy is indicated for women with anovulatory PCOS who have been treated with antiestrogens, either if they have failed to ovulate or if they have a response to clomiphene that is likely to reduce their chance of conception. Patients are started with very low dose gonadotrophin (FSH) and the dose is gradually increased. When the leading follicle reaches 14 mm, the FSH threshold dose is reduced by half.
In some patients, invitrofertilisation (IVF) or even intracytoplasmic sperm injection (ICSI) may be the only option for pregnancy.

Complications

PCOS patients are increased risk of developing chronic diseases which are directly linked to obesity in PCOS.
Non-insulin dependent Diabetes mellitus (NIDDM)
Cardiovascular diseases such as hypertension and coronary heart disease
Endometrial cancer
Infertility
Depression and anxiety

Because of the risk of chronic disorders, PCOS patients are advised to continue follow-up every 6 months.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source – Jeffcoate’s Principles of Gynaecology 7th edition

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