Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) occurs due to hormonal imbalance in the childbearing age (15 to 44). Production of male hormone androgen increases during PCOS. It becomes difficult for a woman to conceive if she is suffering from PCOS.  Due to increased male hormone in the blood, coarse hairs grow on the face and body, even male pattern hair loss. PCOS commonly causes irregular or no menstrual periods. PCOS is one of the risk factors for developing diabetes and heart diseases in the later years and it can also trigger endometrial cancer.

What is polycystic ovary syndrome? 

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder seen in the reproductive age female around the world. Stein and Leventhal were the first to initially described it in 1935. The incidence ranges around 5% to 15% depending on the diagnostic criteria used. We have guidelines based by specialty society that the diagnosis of PCOS must be based on the presence of at least two of the following three criteria: 

  • Chronic anovulation

  • Hyperandrogenism (clinical or biological) & 

  • Polycystic ovaries

Sometimes, it is a diagnosis of exclusion, and clinical conditions that mimic features of PCOS must be excluded. Some of the clinical conditions that need to be excluded are 

  • Thyroid disease, 

  • Hyperprolactinemia, and 

  • Non-classical congenital adrenal hyperplasia. 

At times PCOS is underdiagnosed and frequently can take more than one visit or different physicians to diagnose the condition, and these usually occur in more than a one-year timeframe. Due to delays in diagnosis, it can be a very frustrating process for the patient. Delay in diagnosis can lead to the progression of comorbidities making it more difficult to implement lifestyle intervention, which is critical for the improvement of features of PCOS and quality of life.

What are polycystic ovaries? 

To understand polycystic ovaries we need to know the normal menstrual cycle. In general, normal menstrual cycles happen once in 24-38 days and periods can last for 3-8 days. 

  • The menstrual cycle is divided into two phases, the first phase is Follicular / Proliferative phase which happens immediately after menstruation is dependent on a hormone called oestradiol and this phase is for about two weeks, following which the ovulation happens (release of the egg from the ovary). After, ovulation happens another hormone called progesterone is activated and this phase is known as the Luteal / Secretory phase and again this is for about two weeks. If conceptions don’t happen then the progesterone levels fall and menstruation occurs.

  • In polycystic ovaries the ovulation doesn’t happen thus there is no release of the egg. Since there is no ovulation there is no progesterone release from the ovary. Since there is no progesterone hormone to help the endometrium undergo changes the endometrium continues to grow under the influence of oestrogen hormone. When this endometrium becomes really thick there is breakthrough bleeding and menstruation occurs. As the endometrial lining is thick the menstruation can be very heavy. 

  • As there is no ovulation the egg follicles remain in the ovary and form a cyst. With each passing month, the cysts are pushed to the peripherally of the ovary, and hence in polycystic ovaries, there are twice the number of egg follicles (at least ten cysts 2-8mm in diameter) as compared with the normal ovary.  Ultrasound shows are more than 10-12 follicles arranged in the periphery of the ovary giving the string of pearls or pearl necklace appearance.

What causes polycystic ovary syndrome? 

Exact cause for development of PCOS is not known but it often runs in families. If any of your relatives (mother, aunts, sisters) are affected with PCOS, your risk of developing PCOS may be increased, but definite genetic link has not been found. 

What are the symptoms? 

Irregular or absent menstrual periods

Acne, oily skin

An increase in unwanted hair on face, chest, abdomen, arms and legs (hirsutism)

Some women can experience depression & psychological issues

Weight gain: experiencing a rapid weight gain or having difficulty in losing weight

Infertility: since there is no ovulation women can have infertility issues

How is PCOS diagnosed? 

The doctor may suspect that polycystic ovarian syndrome when you have any two of the following – irregular, infrequent periods or no periods at all, increase in facial body hair and or blood test that shows higher testosterone levels than normal and an ultrasound scan that show polycystic ovaries. is the cause from the symptoms. 

Blood test for hormones in the first week of the menstrual cycle is sometimes used to confirm the diagnosis.

Ultrasound: ovarian morphology measurement is more accurate when done by transvaginal ultrasound. On ultrasound polycystic ovaries are diagnosed when there are more than 10-12 follicles arranged in the periphery of the ovary giving the string of pearls or pearl necklace appearance.

What are the treatment options? 

There is no one specific treatment as such for the condition.  It is mainly symptomatic treatment according to individual patient’s circumstances. 

  • Obesity: make lifestyle modification, paying particular attention to diet and exercise can control this. In overweight (BMI 25 - <30) and obese (BMI 30 & above) PCOS women and adolescents, exercise and calorie limiting diets are best first line medication for weight loss. Various studies have shown that hirsutism can improve as well as regulation of the menstrual cycle and ovulation.  Loosing just 10% of your body weight can bring your periods back to normal.

  • Irregular periods: if the main concern is irregular or no periods, then the usual treatment is the oral contraceptive pill (OC pills) which will almost always restore regular periods, hirsutism and acne. This treatment is obviously not suitable for women trying to conceive. There are some contraindications for OC pills such as women 35 or older, who smoke more than 15 cigarettes daily, uncontrolled hypertension greater than 160/100 and uncontrolled diabetes with severe peripheral vascular disease. You need to consult your doctor and have proper discussion prior to taking OC pills.

  • Excessive hair growth: this requires long-term treatment and can take several months before effects are evident. Cosmetic interventions should be initiated simultaneously while medications start working. Cosmetic options could be bleaching and temporary methods of hair removal. Oral medications are given to reduce excessive hair growth but need to be used for at least 9 months before beneficial effects become apparent. Local cosmetic measures such as hair removing creams, shaving, waxing, bleaching, plucking and electrolysis may prove useful but need to be continually repeated. 

  • Infertility: since there is no regular ovulation happening PCOS can make it difficult to conceive naturally. If weight loss is not successful, then you will need help with ovulation by using drugs. 

What could PCOS mean for my long-term health? 

If you have PCOS, you are at greater risk of developing the long-term health problems such as 

Insulin resistance and diabetes 

Studies have shown that one or two in every ten women with PCOS go on to develop diabetes at some point. Your risk of developing diabetes can be high if you: 

  • are over 40 years of age

  • have first degree relatives with diabetes

  • developed diabetes during a pregnancy (gestational diabetes) 

  • are obese (a body mass index (BMI) of over 30). 

If you have PCOS, you will be advised to have regular check for your sugar levels. If you are diagnosed with diabetes, you will be referred to endocrinologist for further management. 

Cardivascular risk: 

  • Women with PCOS tend to be at high risk for having high blood pressure, which is likely to be related to insulin resistance and to being overweight rather than to the PCOS itself. High blood pressure can lead to heart problems and should be treated by an expert.  

Endometrial cancer 

  • It has been noted that if you have fewer than three periods a year, the lining of the womb (endometrium) can thicken and undergo changes to pre-cancerous conditions and this may lead to endometrial cancer in a small number of women. There are ways to prevent this and ask your doctor for options. Common options are taking a five-day course of progestogen tablets used every three or four months, taking a contraceptive pill or using the intrauterine contraceptive system (Mirena®). Options will vary on whether you are trying to become pregnant or no. PCOS does not increase your chance of developing breast or ovarian cancer. 

Depression and mood swings 

  • Evidence for the increased rate of depression symptoms was found for PCOS women. Screening for depression and anxiety disorder should be done. Appropriate referral and treatment should be given.

Obstructive sleep apnea (OSA): 

  • PCOS due to obesity can lead to snoring and daytime drowsiness, which can again have long term effect on heart. 

How can I do to reduce long-term health risks? 

Have a healthy lifestyle: eat a healthy balanced diet. Diet should include fruit and vegetables and whole foods (such as wholemeal bread, whole-grain cereals, brown rice and whole-wheat pasta), lean meat, fish and chicken. You need to cut down the amount of sugar, salt and caffeine that and eat meals regularly, especially breakfast. Do exercise regularly (30 minutes at least three times a week). 

You should aim to keep your weight to a level that is normal (BMI between 19 and 25). 

The benefits of losing and keeping weight under control include: 

  • Lower risk of developing diabetes 

  • Lower risk of heart problems

  • Lower risk of endometrial cancer 

  • Regular periods and increased chance of becoming pregnant

  • Reduction in acne and a decrease in excess body hair growth and over time this helps in improved mood and self-esteem. 

Have regular health checks:

Once you have been diagnosed with PCOS, you will be monitored to check for any early signs of diabetes and hypertension

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