Polycystic Ovarian Syndrome
Written by Dr.M.D.Mazumdar, MD
Polycystic Ovarian Syndrome is also known as Polycystic Ovarian Disease, Stein Leventhal Disease or Ovarian Dysmetabolic Syndrome.
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 that it occurs when the ovaries start to produce excessive androgens (male hormones). 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.
Another cause of PCOS is believed to be 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.
Symptoms of Polycystic Ovarian Syndrome(PCOS)
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.
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).
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.
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Tests for Polycystic Ovarian Syndrome(PCOS)
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.
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.
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.
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.
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