Polycystic ovary syndrome (PCOS) or polycystic ovary disease (PCOD) is a problem in which a woman's hormones are out of balance. It can cause problems with your periods and make it difficult to get pregnant. PCOS also may cause unwanted changes in the way you look. If it isn't treated, over time it can lead to other health problems, such as diabetes and heart disease. Most women with PCOS grow many small cysts on their ovaries. That is why it is called PCOS. The cysts are not harmful but lead to hormone imbalances. Early diagnosis and treatment can help control the symptoms and prevent long-term problems.
The cause of PCOS is still puzzling. PCOS is thought to arise from a combination of familial and environmental factors that interact to cause the characteristic menstrual and metabolic disturbances. It is now accepted that PCOS is caused by several factors, partly genetic, but the studies about the gene responsible for PCOS is still ongoing. Although not frequent, this disease is also known to occur in men and this genetic predisposition may be expressed as premature balding.
The underlying mechanism by which PCOS affects the body is by insulin resistance. This is most evident in women with a high Body Mass Index (BMI). [BMI is measured by dividing the weight (in Kg) of a person by the square of the height (in meters). For example, if the weight of a patient is 56 kg and the height is 1.6 m, then the BMI will be 56/1.6x1.6=21.8. Ranges for BMI are usually defined as underweight (<19), normal weight (19.1-24.9) and obese (>30)]. In spite of insulin resistance in peripheral sites, e.g. fat tissue, the ovary remains sensitive to insulin. The action of insulin on the liver leads to a decrease in the production of sex hormone binding globulin which results in increased free testosterone (a male hormone).
Clinical sign symptoms:
The symptoms frequently begin at puberty although in many women the syndrome is not fully expressed until later in their reproductive years.
- Menstrual disturbances: Women with PCOS usually presents with oligomenorrhoea (reduced menstrual bleeding), amenorrhoea (absence of menstrual bleeding), prolonged erratic menstrual bleeding. Nearly 90% women with oligomenorrhoea have features of PCOS on Ultrasound. However, the features of PCOS are present only in 30% of women who presents with amenorrhoea.
- Hirsutism, acne and alopecia: Increased facial and body hair (hirsutism) is one of the most common presenting symptoms. About three-quarters of women who present with acne have PCO on ultrasound. Alopecia and more specifically crown pattern baldness have been less commonly reported in women with PCOS.
- Recurrent miscarriage: polycystic ovaries have been identified as being associated with recurrent miscarriage.
- Metabolic: The metabolic aspect of PCOS is obesity and insulin resistance. The distribution of fat in women with PCOS results in an increased waist: hip ratio and is frequently associated with greater insulin resistance than if fat is distributed predominantly in the lower body segment. Some patients may also present with acanthosis nigricans (a feathering pigmented area of tissue in the neck and axillary regions); this is now recognized as a non-specific marker of moderate to severe insulin resistance. Hypersecretion of insulin results in ovarian secretions of androgen leading to hirsutism and menstrual disturbance.
Diagnosis of PCO is primarily by abdominal ultrasound. In ultrasonography, a patient with PCO should have at least one of the following: increased ovarian area (>5.5cm2) or volume (>11 mL) and/or presence of ≥12 follicles measuring 2 to 9 mm in diameter. PCOS can also be diagnosed by measuring the level of several hormones in the blood.
The mainstay of treatment of PCOS still remains in “diet and exercise” and greater emphasis needs to be placed on lifestyle factors. The obesity epidemic may unmask more women with PCOS in the future. Weight reduction in a woman with PCOS will often return her to the other end of the spectrum with ovulatory cycles and improve hirsutism. An asymptomatic non-obese woman who is diagnosed with PCO on ultrasound should be counselled about the advisability of maintaining a normal BMI in the future.
Weight loss: The increasing proportions of obesity in modern society will mean that more women will present with the symptoms of PCOS as an excess of body fat accentuates insulin resistance and its associated clinical sequelae. Obese women with PCOS almost inevitably have the stigmata of hirsutism, acne and irregular or absent ovulation/menstruation. Being overweight makes treatment less effective and less efficient. Weight loss improves ovarian function and reverses some of the associated hormonal abnormalities. For these reasons, weight loss should be the first line of treatment in women with PCOS who are overweight and wish to conceive.
Lifestyle factors in the management of PCOS:
- Alteration of the environmental components of this condition is fundamental to the management of the condition and that pharmaceutical treatment is only used after adequate counselling and action relating to lifestyle alteration. Attention to weight loss altered diet and exercise are important aspects to discuss with the patient as well as stopping smoking and improving psychosocial attitudes.
- Obesity is a costly and increasingly prevalent condition. A study published in the noted medical journal Lancet says India is just behind US and China in this global hazard list of top 10 countries with the highest number of obese people. Fat in excess of the normal can lead to menstrual abnormality, infertility, miscarriage and difficulties in performing assisted reproduction.
- Weight loss induces menstrual regulation in a proportion of women with obesity and anovulation. It was shown that a reduction in the blood level of male hormone androgen with dieting and associated return of menstrual cycles. Strict calorie restriction with a subsequent 5% or greater weight loss led to changes in insulin and Menstruation. Even women with the cause of infertility not related to anovulation (such as tubal blockage or male partner with low sperm count) showed dramatic improvements in assisted reproduction pregnancies.
- This lifestyle modification is put into practice for 6 months. If there is the return of periods, pregnancy etc, no further medical treatment is required. If disorder persists after 6 months, medical treatment may be offered.
Diet for PCOS
A moderate protein, high carbohydrate low fat and intake diet (15:55:30) or a moderate protein, moderate carbohydrate and low-fat diet (30:40:30) with a restricted caloric input is the standard recommended diet in most countries. Concomitant exercise is essential for weight maintenance and contributes to reducing stress and improves the sense of well-being. Weight loss is maintained more effectively when a low-fat diet is followed over longer periods of time. A dietary protocol advocating a moderate increase in protein and a concomitant reduction in dietary carbohydrate also helps. Furthermore, altering the type of carbohydrate with a lower glycemic index (The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100 according to the extent to which they raise blood sugar levels after eating) helps to prevent obesity. World Health Organization (WHO) and Food and Agriculture Organisation (FAO) recommended that people in industrialized countries base their diets on low-GI foods in order to prevent the most common diseases of affluence, such as coronary heart disease, diabetes and obesity. High protein diets are more likely to reduce intake, increase subjective satiety and decrease hunger compared to high carbohydrate diet. Weight loss may be more substantial in the short term but is no better in other diets in the longer term. Weight loss will result from a decrease in energy intake or increase in energy expenditure and this should be the key approach. Women participating in a weight loss program have shown that return of ovulation coincides with a reduction in insulin resistance and fall in central adiposity.
Lifestyle modification suggested for treatment of PCOS in overweight women include:
- Moderate exercise (≥ 30 min/day)
- Dietary modification (Fat ≤30% daily intake)
- For weight loss, establish an energy deficit of 500 to 1000 kcal/day
- Behavior modification, reduction of stress, increased well-being
- Combination of dietary and behavioural therapy and increased physical activity
- Smoking cessation and to stop alcohol consumption
- Moderate caffeine consumption
- Group interaction/intervention to provide support
- Social support by physician, family, spouse, and peers
- Avoidance of “crash diets” and short-term weight loss
- Minor roles for drugs involved in weight loss
- Avoidance of aggressive surgical approaches for majority
- Adaptation of weight loss programs to meet individual needs
Menstrual irregularity secondary to ovulatory disturbance (anovulation) is a significant acute clinical problem in PCOS. If untreated chronic anovulation is associated with an increased risk for endometrial carcinoma. Treatments include birth control pills to regularize periods. A medication called metformin also helps to improve menstrual irregularities/anovulation. Metformin may offer additional protection, by reducing insulin resistance, which has been associated with an increased risk of endometrial carcinoma.
Anti-male hormone therapy is a successful treatment for symptoms of hirsutism including acne. Antibiotic also is useful for the management of acne. Anti-male hormones are prescribed with a low-dose contraceptive in order to induce regular withdrawal bleeding.
For patients who are infertile due to PCOS, clomiphene citrate is generally used for induction of ovulation. Ovulation occurred in 70-80% of cases and pregnancy resulted in 30-40% cases. Another medical treatment that is increasingly used for ovulation induction is metformin, an insulin-sensitizing agent, the most commonly prescribed oral medication for hyperglycemia. A decrease in insulin levels results and as a consequence, a lowering of circulating total and free androgen levels with an improvement of clinical sequelae of the increased male hormone.
PCOS is a subject that continues to be debated amongst the medical and scientific community. Over the past 60 years, tremendous advances have been made in diagnosis and management. It is one of the most common endocrine disorders and in the future, the focus on management is likely to be the prevention of the long-term sequelae associated with insulin resistance.
- Polycystic Ovary Syndrome, Second Edition, Edited by Gabor Kovacs and Robert Norman, Cambridge University Press 2007
- http://www.glycemicindex.com/about.php; The University of Sydney.
- Michael T. Sheehan, MD. Polycystic Ovarian Syndrome: Diagnosis and Management. Clin Med Res. 2004 Feb; 2(1): 13–27.