Polycystic ovary syndrome (PCOS) is a hormonal disorder with over production of male harmone (Androgen) and insulin resistance (Insulin resistance is a condition in which the body produces insulin but does not use it effectively which again lead to horm onal imbalance) that causes verities of symptoms like irregular menstrual periods, overweight ,obesity, hirsuitism (excessive hair growth all over body), acne etc.
Incidence- The condition occurs in about 5 to 10 percent of female population of developed countries .Much higher incidence is reportedin india 3.7 to 22.5% and In Indian adolescents it is 9.13 to 36%..
Cause of PCOD- The cause of polycystic ovary syndrome (PCOS)is not fully understood, but genetics may be a factor. PCOS can be passed down from either your mother's or father's side. PCOS problems are caused by hormonal changes. One hormone change triggers another,which changes another.
How PCOS patients presents-
- Menstrual irregularities- is the commonest problem PCOD patients present with. This can be in the form of scanty menses, prolonged menstrual cycles, prolonged and heavy menses or absent menses.
- Weight gain and obesity- Because of hormonal imbalances most women gradually gain weight. There are few women or adolescents who do not gain weight. They are known as Lean PCOS.
- Male-pattern hair growth ( hirsutism is the excessive growth of thick,dark terminal hair in women where hair growth is normally absent) may be seen on the upper lip, chin, neck, side burn area, chest, upper or lower abdomen, upper arm, and inner thigh.
- Pimples- (Acne) is a skin condition that causes oily skin and blockages in hair follicles.Mostly occurs on face, but sometimes may be seen on back and upper chest
- Infertility - Many women with PCOS do not ovulate regularly, and it may take these women longer to become pregnant. An infertility evaluation is often recommended after 6 to 12 months of trying to become pregnant.
- Metabolic syndrome- Many patients with polycystic ovary syndrome (PCOS) also have features of the metabolic syndrome,including insulin resistance, Diabetes, obesity, and dyslipidemia (abnorma lLipid profile), suggesting an increased risk for cardiovascular disease( CVD ).
Risk Factors for PCOS
- Early or late Menarche- age of first menses.
- Family History of PCOS ,irregular periods or Diabetes.
- Sedentary and improper life style.
Long term sequel of PCOD-
- They are at high risk of developing Diabetes.
- High blood pressure, high cholesterol and heart diseases.
- High risk of developing uterine cancer (endometrial cancer) due to unopposed action of Oestrogen harmone.
- Thyroid Disorders( Hypothyroidism)
- Sleep apnea — Sleep apnea is a condition that causes brief spells where breathing stops (apnea )during sleep. Patients with this problem often experience fatigue and daytime sleepiness.
- Depression and Anxiety.
When patient goes to a doctor with any of the above mentioned symptoms then doctor takes full history, ask for other symptoms and examines thoroughly and then may advice certain tests to confirm the diagnosis.
There is no single test for diagnosing polycystic ovary syndrome (PCOS). You may be diagnosed with PCOS based upon your symptoms, blood tests, and a physical examination. Expert groups have determined that a woman must have two out ofthree ( Rotterdam criteria ) of the following to be diagnosed with PCOS:
- Irregular menstrual periods caused by anovulation or irregular ovulation.
- Evidence of elevated male harmone (Testesterone) levels. The evidence can be based upon signs (excess hair growth, acne, or male-pattern balding) .
- Polycystic ovaries on pelvic ultrasound.- it shows enlarged ovary with multiple cysts. This is seen in almost 30% of cases.
- In women with moderate to severe hirsutism (excess hair growth), blood tests for testosterone and Indehydroepiandrosterone sulfate (DHEA-S) may be recommended.
- TSH and Prolactin harmones should also bed one as Hypothyroidism and or Hyperprolactinimia may be associated with PCOS.
- If PCOS is confirmed, blood glucose and cholesterol testing are usually performed.
- Anoral glucose tolerance test is the best way to diagnose prediabetes and/or diabetes.
In adolescents, presence of oligomenorrhea (scanty menses) or amenorrhea (absent menses) beyond two years of menarche should be considered an early clinical sign of PCOS, followed by (Rotterdam criteria ) of adults for diagnosis of PCOS as mentioned above.
Minimal diagnosis of PCOS in adolescents should include 5 tests-
- Serum total testosterone (cut off 60 ng/dL)
- Oral glucose tolerance test (OGTT) zero, two hours after 75 gm glucose load.
- Serum 17– hydroxy progesterone (assessed at 8 am)
- Serum TSH Serum and
- prolactin levels
MANAGEMENT OF PATIENTS WITH PCOS
Both pharmacological and non-pharmacological management strategies are crucial in the overall management of PCOS. Usually treatment depends upon the symptoms for which patient comes. As PCOS can not be cured permanently, long term treatment plans should be given to manage her bothering symptoms and also to prevent long term sequeli.
Treatment- usually depend upon the symptoms for which patient has come. But life style modification forms the main stay of treatment. Regular exercise,a healthy diet ,weight control, and not smoking are all important parts of treatment for polycystic ovary syndrome (PCOS)
Physical activity- In adults and adolescents with PCOS, daily strict physical activity sessions for at least 30min/day or 150min/ week are recommended.
Weight loss — Weight loss is one of the most effective approaches for managing insulinabnormalities, irregular menstrual periods, and other symptoms of PCOS. Forexample, many overweight women with PCOS who lose 5 to 10 percent of their bodyweight notice that their periods become more regular. Weight loss can often beachieved with a program of diet and exercise.
Diet -it is recommended to follow calorie restricted diet (low carbohydrate and fat,high protein diet)
There are a number of options available to treat obesity. These options are identical to those recommended for women without PCOS and include diet and exercise, weight loss medications (although their use is limited), and weight loss surgery.
Weight loss surgery may be an option for severely obese women with PCOS. Women can lose significant of weight after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes.
Oral contraceptives — Oral contraceptives (OCs; with combined estrogen and progestin) are the most commonly used treatment for regulating menstrual periods in women with polycystic ovary syndrome (PCOS). OCs protect the woman from endometrial (uterine) hyperplasia or cancer by inducing a monthly menstrual period. OCs are also effective for treating hirsutism and acne.
Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is“cured, irregular cycles generally return when the OC is stopped. Oral contraceptives decrease the body's production of male harmone ( androgens).
Anti-androgen drugs (such as spironolactone) decrease the effect of androgens. These treatments can be used in combination to reduce and slow hair growth. Oral contraceptives and anti-androgens can alsoreduce acne.
Metformin — Metformin is used to decrease insulin resistance in these patients. It improves the effectiveness of insulin produced by the body. It was developed as a treatmentfor type 2 diabetes but may be recommended for women with PCOS with obesity and insulin resistance.
If a woman does not have regular menstrual cycles, the first-line treatment is a hormonal method of birth control, such as birth control pills. If the woman can not take birth control pills, one alternative is to take metformin; a progestinis usually recommended periodically to have withdrawal bleeding in addition to metformin, for six months or until menstrual cycles are regular.
Metformin may help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.
Treatment of infertility — If tests determine that lack of ovulation is the cause of infertility, several treatment options are available.These treatments work best in women who are not obese.
The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest amount of weight loss may allow the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.
Ovulation inducing drugs (like clomiphene etc) are also used in conjunction with Matformin. Your doctor will discuss with you about it.
Prevention- (PCOS) cannot be prevented. But early diagnosis and treatment helps prevent long-term complications, such as infertility, metabolic syndrome, obesity, diabetes, and heart disease.