- 1 What is polycystic ovarian syndrome?
- 2 What causes polycystic ovarian syndrome?
- 3 What are the symptoms of Poly cystic ovarian syndrome?
- 4 How is Poly cystic ovarian syndrome diagnosed?
- 5 How is Poly cystic ovarian syndrome treated?
- 6 What are the complications of polycystic ovarian syndrome?
What is polycystic ovarian syndrome?
Polycystic ovarian syndrome, commonly known as PCOS, Polycystic ovary syndrome (PCOS) is the most common reproductive endocrinopathy of women during their child bearing years with a reported prevalence of 4-8%. It is a major cause of infertility, amenorrhea or oligo menorrhea.
It is a condition where there are increased amounts of sex hormones such as oestrogen and progesterone in a woman’s body. This results in a growth of the ovarian cysts. Polycystic ovarian syndrome can affect the woman’s menstrual cycle, their fertility; hear function and their appearance as well. Polycystic ovarian syndrome was first described by Stein and Leventhal in 1953.
Polycystic Ovary – PCO – is an ultrasound diagnosis. Whereas Polycystic Ovarian Syndrome – PCOS – is a clinical syndrome involving a Polycystic Ovary with either amenorrhea, oligo menorrhea, hirsutism, anovulation and other signs of androgen excess like acne and crown pattern of baldness.
What causes polycystic ovarian syndrome?
The exact cause of polycystic ovarian syndrome is not known. However, many doctors believe that the hormones play an important role in the pathogenesis of polycystic ovarian syndrome. In addition to hormones, there is evidence that genes too play a major role in the pathogenesis of this disease.
There is evidence of autosomal transmission of responsible genetic sequences for PCOS. It is possible that one gene (or a series of genes) may render ovary susceptible to insulin stimulation of androgen secretion while blocking follicular maturation. This fact is further confirmed by the evidence of increased risk of PCOS in women who have a family history of PCOS with either their mother or sister.
Another important factor that contributes to the pathogenesis of the disease is the over production of the androgen hormones. Androgen is a male sex hormone but it is also produced by females in smaller quantities. However, patients with poly cystic ovarian disease often produce a greater quantity of androgen hormone compared to women without this condition. This will affect the development and the release of eggs or ova from the ovary during ovulation.
What are the symptoms of Poly cystic ovarian syndrome?
The signs and symptoms of poly cystic ovarian syndrome often start soon after menarche that is the age of a woman when they first start to menstruate. The severity and the type of symptoms each patient may experience will vary from person to person.
There is spectrum of clinical presentations. At one end of the spectrum are the women who may have polycystic ovaries and yet ovulate and who have no dermatological manifestations such as acne or hirsutism. At the other end of the spectrum there may be women with menstrual disturbances, oligo amenorrhea, increased hair growth, acne, and crown pattern of baldness and evidence of insulin resistance.
Since there is reduction in the female sex hormones in a patient with PCOS, and a rise in the male sex hormones, these patients will show certain masculine characteristics such as:
- Excessive growth of body hair on the face, chest, thumbs or toes
- Reduced size of the breasts
- Change in voice – these patients may have a deeper voice
- Hair loss with a crown pattern of baldness
Other symptoms that patients with PCOS may develop are:
- Increase in the weight
- Subfertility – These patients may find it difficult to become pregnant
- Insulin resistance – This is another common feature seen especially in women who are overweight or obese. These patients will have a higher random blood glucose level and a fasting blood glucose level as a result of the insulin resistance. Insulin resistance represents a common component of the syndrome that is present not only in obese PCOS, but also in normal weight PCOS, in adolescent girls with hyper androgenism, in women with multi follicular ovaries, and in apparently normal women with polycystic ovaries.
The insulin resistance leads to derangement of the regulation of androgen synthesis and therefore prevents the down regulation of LH receptors. This, somehow, leads to an increase in the androgen and estrogen secretion. There is development of lipid abnormalities in oligo menorrheic women with PCOS and hypertriglyceridemia is also a direct result of the insulin resistance. Besides, there is disturbance in cholesterol metabolism due to alterations in sex-steroid concentrations.
Out of all, the most characteristic common symptom of polycystic ovarian syndrome is the irregular menstrual periods. Any patient who complains of irregular menstrual periods should be always investigated for this condition.
The presence of a woman in this spectrum is possibly predetermined by genetic factors, but her position on the spectrum is likely to be related to life-style and particularly by the body mass index. Although the exact trigger that causes the expression of the syndrome is unknown, it is likely that body mass index is involved and women at the PCO end may move to the PCOS end if they increase their body weight. Weight reduction in a woman with PCOS will often return her to the other end of the spectrum with ovulatory cycles and improved hirsutism.
Asymptomatic non-obese women who are diagnosed with Poly cystic ovaries on ultra sound scan should be counselled about the sense of maintaining a normal body mass index in the future. Should symptoms of amenorrhea or hyper androgenism develop, specialist attention should be sought regardless of their weight.
How is Poly cystic ovarian syndrome diagnosed?
There is no diagnostic test available for Poly cystic ovarian syndrome but with the help of history, examination and investigations, a diagnosis of PCOS can be felt.
Ultra sound scans of the pelvis.
An ultrasound scan of the pelvis to visualize the ovaries will help your gynaecologist to identify the presence of ply cystic ovaries.
Your gynaecologist will look for the Poly-follicular Pattern. This is the presence of excessive number (more than 10) of small echoless regions less than 10 mm in diameter is strongly suggestive of PCO. In young patients these follicles are more peripherally placed giving the Neck-lace appearance. Ovarian Stromal hypertrophy and hyper echogenicity are the most reliable USG signs to distinguish between PCO and multi follicular ovary.
Earlier other measurements such as Ovarian Length, Utero-ovarian Index (uterine width : ovarian length ratio), Sphericity Index (ovarian width: ovarian length), Ovarian Area Assessment and Ovarian Volume were all measured but were unable to take accurate measurements of these parameters because of its difficulty an therefore this is not a very popular method used now a days.
The advantage of doing an ultra sound scan is that the ultra sound scan is simple, non-invasive and allows repeatable measurements. It can assess both—the follicles near the surface as well as the dense stroma. Transabdominal ultra sound scan fails to detect PCO in 30% cases as compared to 100% diagnosis by transvaginal USG6.
Blood tests to measure the levels of sex hormones.
Hormone Assays for raised LH and Testosterone, LH: FSH ratio of more than 2:1, Absolute LH values are all used for diagnosis of PCOS and the absolute LH value appears to be the most useful hormonal assay in the diagnosis of PCOS.
Limitations of ‘Hormone Assays’ are that the LH is released in a pulsatile manner and therefore measuring hormone levels only once may be misleading.
How is Poly cystic ovarian syndrome treated?
Polycystic ovarian syndrome has no cure but its signs and symptoms can be treated and the condition can be controlled. The treatment of PCOS mainly focuses on controlling the symptoms and also to manage the condition so that complications are prevented. Since the management mainly depends on the specific symptoms each woman face, the treatment will vary from one person to the other. The following are a few ways that will help to control the symptoms of Poly cystic ovarian syndrome:
Life style changes will remain the hallmark of management of this lifelong problem. There is a strong relationship between obesity and PCOS. Approximately 50% of the women have a BMI of more than 30 kgs/sqm2 (obese).The girl should be explained of the possible problems of weight gain and disease progression. The key will be to keep the BMI in the normal range of 18-25, if possible at its lower end. This single measure is most effective to ward off all the manifestations.
The main life style changes that can be followed are the dietary changes and exercises. Low calorie diet with reduced carbohydrate intake with regular and moderate exercises is necessary for weight loss. Eating a healthy diet and exercising regularly is recommended to all patients who are diagnosed with poly cystic ovarian syndrome, especially those women who are overweight or obese. These life style changes not only help to regularize the menstrual periods, but also help to lower the blood glucose levels in the body.
There is convincing data that apart from the well-known hazards of smoking on cardiovascular and respiratory system, there is associated reduction of fertility potential. It is therefore, prudent to motivate the women to change their life-styles even before embarking on ovulation induction treatment, as the treatment is then more likely to be successful and also improve their long-term health
Diabetic medication to lower the blood glucose levels as well as the androgen levels.
Metformin, by its effect on insulin resistance reduces androgen levels and thereby regularize the menstrual cycles. This drug is generally used in girls showing signs of hyper androgenism or insulin resistance. Since metformin helps to reduce the levels of androgen in the body, it will therefore stop the excessive hair growth and reduce the acne as well. It not only reduces the androgens levels, but also helps to reduce the blood sugar levels.
Ovulation Induction by Clomiphene Citrate, Human menopausal gonadotropin (HMG)/ Human chorionic gonadotropin (HCG), Follicular stimulating hormone (FSH)/HCG will bring back regularity in menses and fertility. This is indicated in patients who have been diagnosed with poly cystic ovarian syndrome and complains of subfertility as well. Ovulation induction, as the name suggests, induces ovulation in these women and following this treatment they are advised to have timely intercourse to improve the chances of pregnancy. If timely intercourse fails, these patients will be advised to undergo cycles of intra uterine insemination as well.
Clomiphene citrate is an anti-oestrogen. This is considered the first line therapy for infertility caused by anovulation. The dose is 50-100 mg/day from day 2-6 of natural or progestogen induced bleeding.
Inhibition of oestrogen feedback at the hypothalamic pituitary level leads to a surge in FSH with growth of the Graafian follicle and increase in oestrogen. When successful the follicle continues to enlarge and eventually ruptures releasing an ovum, i.e. ovulation. It can be used along with hCG to improve mid cycle LH surge.
Approximately 20-25% of women does not respond to clomiphene and are called clomiphene resistant. The non-responders are mainly obese women with insulin resistance and hyper androgenemia.
Some women who experience troublesome side-effects with clomiphene benefit from tamoxifen 20 to 40 mg, days 2 to 6. Monitoring should be same as for clomiphene citrate.
Patients who fail to respond to clomiphene citrate therapy can be offered gonadotropins for ovulation induction. Available preparations include combination of LH and FSH or purified FSH, which is preferred in view of high endogenous LH. Exogenously administered gonadotropins stimulate the ovary directly resulting in follicular maturation, and hCG is then given to trigger release of mature ovum. Because of the increased cost of therapy and risk of hyper stimulation and multiple pregnancies, specialist supervision and close monitoring is compulsory.
GnRH agonist has been used as an adjunct for induction of ovulation with gonadotropins.The results are good but it is still not clear if they are more effective compared to therapy with gonadotropins alone.
Laparoscopic Ovarian Drilling
Diathermy or ‘drilling’ of the ovarian stroma at Laparoscopy has been shown to restore ovulatory cycles in women with clomiphene resistant poly cystic ovarian syndrome. Generally the ovulation rates are 70- 90% and pregnancy rates are 40-70%. The duration of effect appears to be 12-18 months.
Laparoscopy must not be considered as the first line of treatment. Clomiphene citrate remains the first line of therapy for an anovulatory patient with PCOS. For resistant patients, the laparoscopic techniques may have the advantages over gonadotrophin therapy and can be offered. However, if laparoscopy is done for infertility and PCOS is observed, cauterization of the ovaries may be done at the same time to avoid a secondary surgical laparoscopy.
The long-term consequences of ovarian drilling are still unclear but there is concern about future occurrence of premature ovarian failure and of peri ovarian adhesion formation.
What are the complications of polycystic ovarian syndrome?
The possible complications that women with poly cystic ovarian syndrome can develop are:
- High blood pressure also known as hypertension
- High cholesterol levels
- Anxiety and depression
- Endometrial cancer
- Heart attach
- Diabetes mellitus
- Breast cancer
These women therefore need long-term monitoring. Although PCOS has molecular genetic factors responsible, modification in life-style, proper treatment and monitoring can minimize the problems very significantly.
If you have been diagnosed with poly cystic ovarian syndrome and is now pregnant, then your health care provider will refer you to an obstetrician and they will manage you as a high risk pregnancy. This is because of possible complications that can arise from PCOS. Women who have been diagnosed to have PCOS and is pregnant, have a higher chance of miscarriages, developing diabetes mellitus during pregnancy (gestational diabetes), and premature deliveries and therefore preterm babies. Hence these patients are usually categorized as high risk pregnancies and are monitored very closely.