Written by Dr.M.D.Mazumdar, MD

Polycystic Ovarian Syndrome (PCOS) is also known as Polycystic Ovarian Disease, Stein Leventhal Disease or Ovarian Dysmetabolic Syndrome.

What is PCOS?

PCOS is a disease of the reproductive tract in young adult women. It is characterized by a combination of multiple symptoms like irregular and heavy periods, occasional amenorrhea, obesity, hirsutism, and sometimes infertility. These symptoms occur due to imbalance of various hormones.

PCOS occurs in about 5- 10% of all women. It occurs in all races and communities.

Although more common in women in the reproductive age group, some cases are also seen in young teenagers. But it is rare above the age of 40 years.

Causes of Polycystic Ovarian Syndrome

The exact cause of PCOS is not known. It is believed to be due to hormonal imbalance brought on by a combination of genetic, environmental and lifestyle causes.

• Insulin resistance: Insulin levels are frequently higher than usual in PCOS patients. The ovaries and their capacity to ovulate may be impacted by the high insulin levels . Additionally, it may result in a rise in androgen (male hormones) production. This may result in signs like acne, increased body hair growth, and weight gain.
  The trigger for this excessive production of male hormones is believed to be either a high leutinising hormone (LH) level or a high insulin level in the blood.

• Hormonal imbalances: PCOS is characterized by an imbalance of estrogen, progesterone, and androgen hormones. The level of androgens is higher than normal, while estrogen and progesterone may be lower than normal. This can lead to irregular periods, difficulty ovulating, and the development of small cysts on the ovaries.

• Genetics: PCOS tends to run in families, suggesting that there may be a genetic component to the disorder. It has been seen that if someone is diagnosed with PCOS, careful history will reveal that mothers, sisters and other female relatives have similar symptoms to a greater or lesser degree.

• Diabetes:Women with a history of diabetes in the family are also at increased risk of developing PCOS since the causes of diabetes and PCOS are very similar - for example , insulin resistance and hormonal imbalance.

• Inflammation: Some studies have suggested that chronic low-grade inflammation may play a role in the development of PCOS. Some inflammatory markers like white blood cells, C reactive protein (CRP) and interleukin is higher in PCOS. The reaction is referred to as low-grade inflammation. According to research, patients with PCOS experience a specific kind of chronic, low-grade inflammation that causes their polycystic ovaries to produce excessive androgens.

• Obesity : An important related factor is obesity. Since fatty tissues produce estrogen, excessive fat increases the level of estrogen in the blood. This then starts off other hormonal variations. But, it has not been established whether obesity is the result or the cause of Polycystic ovarian Syndrome.
  Obesity causes increased hormonal imbalance and insulin resistance leading to PCOS. At the same time, PCOS suppresses the metabolic rate of the body leading to obesity.

• Environmental factors like, stress, lack of physical activity, sedentary lifestyle and exposure to certain toxins may also play a role in the development of PCOS.

Symptoms of Polycystic Ovarian Syndrome(PCOS)

There are multiple symptoms of PCOS. Not all symptoms are seen in each woman. Some women may not have symptoms at all.

Amenorrhea/Irregular Periods: The chief complaint in almost all women with PCOS is amenorrhea or irregular menstrual periods. Usually, the periods do not occur for 2 -3 months and are then followed by heavy bleeding. This irregularity is due to irregular ovulation. A woman with PCOS may have fewer than eight periods in a year.

Infertility: Infertility is very often the first complaint. Subsequent tests reveal that the cause of infertility in PCOS is irregular ovulation from the ovaries.

Obesity: Most women who suffer from PCOS are also overweight. Fatty tissues, especially peripheral fatty tissues are hormonally active, and they produce estrogen which causes hormonal imbalance and disrupts ovulation. The weight gain is mostly around the abdomen.

Hirsutism: Hirsutism means the growth of excessive body hair in a masculine pattern. In PCOS, it occurs due to excess male hormones produced by the ovaries. There is growth of hair on the cheeks, above the upper lips, on the chest and on the arms and legs. There may even be male pattern baldness in some women.

PMS Symptoms: PMS symptoms like sensations of bloating, water retention, mood swings, irritability, nausea, abdominal cramps, backaches are also common.

Acne/Dandruff: Acne and dandruff are both due to excesive androgens (male hormones). Androgens can stimulate the oil glands in the facial skin to produce excessive oils. This can then lead to acne. Most women with PCOS have acne which may also affect the upper chest, back and neck.

Acanthosis Nigricans: These are dark blackish or brownish patches that occur in response to insulin resistance. The patches are rough to the touch and are mostly present at the back of the neck, though they may also be seen in skin creases below the breast, arms and thighs.

Depression and anxiety: Mood changes due to hormonal imbalance and irregular periods are quite common.

Sleep Apnea and Headache : Headache may be triggered by hormonal imbalance, depression and mood swings. Sleep apnea is more common in women who are overweight - especially if they also have PCOS. The risk for sleep apnea is 5 to 10 times higher in women who have both obesity and PCOS than in those without PCOS.

Tests for Polycystic Ovarian Syndrome(PCOS)

Blood Tests

LH:FSH Ratio: PCOS is associated with a high leutinising hormone (LH) level with a normal Follicular Stimulating Hormone (FSH) level. Normally, the ratio of LH:FSH is 1:1, but in PCOS, this ratio can get altered to 2:1 or even more.

Androgen level: The androgen or male hormone levels are found to be much higher than normal levels. The various androgens that need to be tested are free testosterone, DHEAS and androstenedione.

Insulin level: Fasting Insulin levels are found to be much higher than normal. A fasting glucose:insulin ratio less than 4.5:1 can indicate insulin resistance. Insulin resistance is the body's inability to properly use insulin to convert blood glucose into energy.

Since the blood sugar level continues to be high even on adequate levels of insulin, the body tends to produce higher and higher quantities of insulin to convert the blood sugar. This causes a high insulin level in women with PCOS.

Blood Sugar level: Blood Sugar metabolism is frequently impaired in PCOS. Fasting blood sugar and post prandial (after meals) blood sugar levels should be tested. A Glucose Tolerance Test (GTT) is also necessary if blood sugar is found to be normal.

Cholesterol Levels: Impaired lipid metabolism may occur together with impaired blood sugar metabolism leading to an increase in both HDL and LDL cholesterols.

Thyroid Hormone level: PCOS is often associated with abnormalities of other endocrine glands. So, TSH, T3 and T4 levels should be tested. Very low or very high thyroid hormone levels are associated with anovulation.

Prolactin level: Prolactin is a hormone produced in the pituitary gland and is mainly responsible for the growth and function of the breasts in pregnancy. High prolactin levels are often found in PCOS. Hyperprolactinemiacan cause symptoms similar to PCOS so a test for the prolactin level will help in the diagnosis.

Ultrasonography

Ultrasound of an Ovary in PCOS

Ultrasonography is one of the main diagnostic aids in Polycystic Ovarian Syndrome (PCOS).

A normal ovary shows a number of follicles in various stages of growths and thus of various sizes.

In a polycystic ovary, the follicles are enlarged and form cysts arranged around the periphery of the ovary. This produces, what is called a ' necklace appearance' on ultrasound.

The ovary is also increased in size and on direct visualization, shows a thick whitish surface due to thickening of its cortex.

Treatment of PCOS

Treatment of Polycystic ovarian Syndrome can be by either medicines or surgery or a combination of both.

Lifestyle Changes: Treatment for PCOS should start with a proper explanation of the condition. Losing weight through a healthy diet and regular exercise should be encouraged. This can help regulate menstrual cycles, improve insulin sensitivity, and reduce androgen levels. Weight loss can also lower insulin sensitivity and decrease the androgen levels.

Metformin: Metformin is one of the first lines of treatment in PCOS. It works at various levels in the body to reduce insulin resistance. It reduces the production of glucose in the liver, reduces glucose absorption from the intestinal tract and increases utilization of glucose in the muscles and peripheral tissues of the body. This causes lowered insulin production whch in turn causes lowered androgen production in the ovaries - all of which go towards management of PCOS.

Clomiphene Citrate: Clomiphene Citrate, available as Clomid, Fertomid etc. is also necessary in the management of PCOS. Its main function is to react with the estrogen receptors in the body, blocking them from the estrogen hormone in the blood.

Since the pituitary gland receives signals from the receptors about the estrogen level in the blood, lack of signals form the receptors is perceived as a low estrogen level in the blood. The pituitary then produces more and more FSH in an attempt to stimulate development of follicles in the ovaries and increase the estrogen level.

The high FSH manages to overcome the inhibitions of hormones like LH and androgens to stimulate the ovary and cause ovulation.

Birth control pills: Birth control pills can help regulate menstrual cycles. But they do not affect the insulin levels or reduce androgen levels.

Gonadotrophins: Injections of FSH and LH may be given when there is failure to respond to clomiphene citrate. The disadvantage is that that these are fairly expensive.

Surgery: Surgery was earlier recommended in women who had failed to get pregnant on medical treatment and in women who had developed ovarian hyperstimulation syndrome while on drugs like Clomiphene citrate and FSH/LH.

The main idea behind ovarian surgery for ovulation was to puncture the cysts on the surface of the ovaries - called 'ovarian drilling'. This was often seen to reduce the level of androgens in the blood and stimulate ovulation in more than 70% of women.

But recent research suggests that surgery can do more harm than good by promoting infections and scar formations. It is now rarely, if ever, carried out.

Can PCOS be Prevented?

Currently, there is no known way to prevent polycystic ovary syndrome (PCOS) since the exact cause is not fully understood. However, some lifestyle changes can be suggested to help reduce the risk of developing PCOS.

• Regular Exercise: Regular exercise and a active lifestyle will decrease obesity, improving the hormonal balance and reducing teh risks of PCOS.

• Balanced diet: Eating a balanced diet will help increase insulin sensitivity and reduce inflammation. A balanced diet should contain low carbohydrates, high proteins, plenty of fruits and vegetables and whole grains.

• Avoiding smoking and excessive alcohol consumption: These habits can increase the risk of developing PCOS.

• Stress: Stress, due to any cause can trigger hormonal imbalance and worsen PCOS symptoms. Methods for managing stress, such as exercise, meditation, or counselling are necessary to prevent PCOS.

• Monitoring symptoms: It is important to see a doctor to rule out PCOS or other disorders if a woman has a family history of the condition or exhibits symptoms like irregular periods, excessive hair growth, or acne.

While there is no way to prevent PCOS, early diagnosis and treatment can help manage symptoms and reduce the risk of complications.

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