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Polycystic Ovarian Syndrome


Polycystic Ovarian Syndrome or PCOS is the commonest cause of menstrual problems and affects 5-10% of women in the reproductive age group.
The problem usually originates in adolescence and since at this stage in their lives, all girls have irregular periods for a few months or years after starting periods, the diagnosis is missed. There are however warning signs and tell tale marks on investigations, which if picked up at the right time, can nip the disease in the bud.
Contrary to its name, demonstration of polycystic ovaries is not essential to its diagnosis although it is usually present in most cases. Upto 25% of normal women may also have similar features.

Polycystic Ovary Syndrome affects an estimated 5-10 percent of women of childbearing age and it is a leading cause of infertility. It is the most common hormonal problem among reproductive age women.

Women with PCOS may have some of the following symptoms:

  • Obesity or weight gain - Commonly a woman with PCOS will have what is called an apple figure where excess weight is concentrated heavily in the abdomen, similar to the way men often gain weight, with comparatively narrower arms and legs. The waist: hip ratio is higher (> 0.85) than on a pear-shaped woman. There is not only a tendency to gain weight but also considerable difficulty in losing weight. Weight also tends to bounce back the moment active efforts are stopped. It should be noted that most (40-60%), but not all, women with PCOS are overweight.
  • Amenorrhea (no menstrual period), Oligomenorrhoea (infrequent menses), and/or irregular bleeding - Cycles are often greater than six weeks in length, with eight or fewer periods in a year. Irregular bleeding may include lengthy bleeding episodes, scant or heavy periods, or frequent spotting. This is due to the fact that the eggs fail to be released from the follicles due to thickened ovary capsule as well as changed hormonal milieu.
  • Hyperandrogenism - Increased serum levels of male hormones. Specifically, testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS).
  • Infertility - Infertility is the inability to get pregnant within six to 12 months of unprotected intercourse, depending on age. With PCOS, infertility is usually due to ovulatory dysfunction.
  • Cystic enlarged ovaries - Classic PCOS ovaries are enlarged and have a "string of pearls" or "pearl necklace" appearance with many cysts (fluid-filled sacs). The texture or stroma of the ovary is thickened.
  • Insulin resistance, hyperinsulinemia, and diabetes Insulin resistance is a condition where the body's use of insulin is inefficient. It is usually accompanied by compensatory hyperinsulinemia - an over-production of insulin. Both conditions often occur with normal glucose levels, and may be a precursor to diabetes.
  • Dyslipidemia (lipid abnormalities) - Some women with PCOS have elevated LDL and reduced HDL cholesterol levels, as well as high triglycerides.
  • Hypertension (high blood pressure) - Blood pressure readings over 140/90.
  • Hirsutism (excess hair) - Excess hair growth such as on the face, chest, abdomen.
  • Alopecia (male-pattern baldness or thinning hair) - The balding is more common on the top of the head than at the temples.
  • Acne/Oily Skin/Seborrhea - Oil production is stimulated by overproduction of androgens. Seborrhea is dandruff - flaking skin on the scalp caused by excess oil.
  • Acanthosis nigricans (dark patches of skin, tan to dark brown/black) - Most commonly on the back of the neck, but also but also in skin creases under arms, breasts, and between thighs, occasionally on the hands, elbows and knees. The darkened skin is usually velvety or rough to the touch.
  • Acrochordons (skin tags) - Tiny flaps (tags) of skin that usually cause no symptoms unless irritated by rubbing.
    Suspecting PCOS Questionnaire
    Here is an easy scoring chart by which you can gauge what are your chances of having Poly Cystic Ovarian Syndrome. Score one point for each item unless otherwise indicated.

  • Section I: Menstrual Irregularities
    When not on birth control pills, do you have or have you ever had any of the following:
    Eight or fewer periods per year
    No periods for an extended period of time (4 or more months)
    Irregular bleeding that starts and stops intermittently
    Fertility problems
    (Score 2 points if you have seen a fertility specialist or been treated
    with fertility drugs to induce ovulation.)
  • Section II: Skin Problems
    Score one point for each item unless otherwise indicated.
    Adult acne or severe adolescent acne
    Excess facial or body hair, especially upper lip, chin, neck, chest and/or abdomen
    Skin tags
    Balding or thinning hair
    Dark or discoloured patches of skin on your neck, groin, under arms or in skin folds
    (Score 2 points if you answer yes to this question.)
  • Section III: Weight and Insulin-Based Problems
    Score one point for each item unless otherwise indicated.
    Excess weight or difficulty maintaining weight
    (Score 2 points if your excess weight is centred on your middle.)
    Sudden unexplained weight gain
    Shaking, lack of concentration, uncontrollable hunger and/or mood swings after meals
    Type II Diabetes (Score 2 points if you answer yes to this question.)
    Family history of Type II Diabetes, Heart Disease or Hypertension
  • Section IV: Related Problems*
    *Although there is little or no documented research, many women with PCOS have experienced the following problems. Score each item in this section 1/2 point.
    Migraines
    Depression and/or anxiety
    Eating disorders
    Pregnancy complications such as gestational diabetes or excess amniotic fluid
Your Score
Possibility of PCOS
0-4
PCOS is unlikely.
5-9
If you have specific health concerns and score in this range you may want to consider talking to a Gynaecologist about the possibility of PCOS as well as other disorders.
10-15
The majority of women who are diagnosed with PCOS score in this range. If you scored in this range you should see a Gynaecologist about the possibility of PCOS.
16-20
Urgent consultation with a Gynaecologist for PCOS or other endocrine-related disorders.

The exact cause of PCOS is unknown. There are studies being conducted to see if there may be a genetic link - that PCOS is passed along in families. Just as one might have a genetic predisposition to diabetes, one might also have a disposition to PCOS.

No, it is a condition that is managed, rather than cured. Treatment of the symptoms of PCOS can help reduce risks of future health problems.

At this time, there is no single definitive test for PCOS. This is because no exact cause of PCOS has been established yet. This is why there is a wide-range of opinion on how to diagnose and treat PCOS.

The diagnosis requires assimilation of information gathered from symptoms, physical examination, ultrasonography of the ovaries and various blood tests.

An ultrasonography of the ovaries is usually done transvaginally - where a probe is placed into the vagina to gain view of the ovaries. In young unmarried girls, an abdominal ultrasonography may be needed, but this tends not to give as clear a view.
A classic PCOS ovary is enlarged and has numerous small cysts or pearls. These pearls may be arranged in a 'necklace' or may be scattered throughout the ovary. The cysts are usually 8-10 in number and have sizes less than 10mm. The polycystic ovary tends to be enlarged to 1.5-3 times the size of a normal ovary and often has an increase in the stromal tissue in the center of the ovary and around the follicles.

Much of the blood work that should be done in diagnosing or ruling out PCOS is the same as a basic fertility workup; however, there are a couple of additional tests for insulin resistance that should be added, as well as some cholesterol screening to evaluate general health status because of the future risks associated with PCOS.
A good basic screening would include:
Fasting comprehensive biochemical and lipid panel
2-hour GTT with insulin levels (also called IGTT)
LH:FSH ratio
Total testosterone
DHEAS
SHBG
Androstenedione
Prolactin
TSH

Timing is most important as far as hormone tests are concerned. Do make sure you contact the programme coordinator or the Doctor at the Clinic to ensure that the tests are done at the correct time.

An LH level higher than the FSH level suggests the existence of PCOS. However the ratio between the two has only a suggestive value and not a diagnostic value by itself. Thus is no longer used for diagnosis. In a sub fertile patient, however, it does help in planning the treatment and evaluating the response to it.

A good number of PCOS patients have under-active thyroid glands. Since many of the symptoms are the same, evaluation of the thyroid gland with a blood test for thyroid stimulating hormone (TSH) should be a part of the evaluation for PCOS. The TSH is almost always the only test needed to evaluate thyroid function. Likewise, PCOS should be evaluated in the patient with under-active thyroid gland.

PCOS is associated with increased risk for endometrial hyperplasia, endometrial cancer, insulin resistance, type II diabetes, high blood pressure, high cholesterol and heart disease.

In Insulin Resistance, although Insulin is present in the body, except ovary, all other tissues of the body develop some sort of a resistance to it. In trying to flog a dead horse, the body system flogs the Pancreas (the organ where insulin is produced) to produce more Insulin to produce Hyperinsulinaemia.

At least 30 percent of women with PCOS are insulin resistant, although some investigators claim a much stronger association exists. Hyperinsulinaemia as explained above works selectively on the ovaries and stimulates them to produce more androgen or male hormones. It also reduces the binding of the free androgen thereby creating an environment where plenty of free male hormones are circulating the blood and in the local tissues of the ovary. This forms the starting point for formation of poly cystic ovaries and ultimately leading to the syndrome.


While insulin resistance is frequently accompanied by excess weight, there are thin women who are insulin resistant or type II diabetic. Unfortunately, lean women may not have as much success reducing insulin resistance through lifestyle changes as their overweight counterparts, but diet modifications and increased exercise often provide some benefit. About half the women with PCOS are obese which means the other half is not.

Like diagnosis, there is no single treatment that fits all patients. Each patient requires a tailor made therapy designed for her. The treatment for an adolescent girl with weight problems would be different from a 28yr old lady trying to conceive which would again be different from someone who has problems with excess facial hair or acne. Whatever the age and whatever the problem, weight loss forms the first line of treatment. It has been seen that even a loss of 5% of body weight regularizes periods; kick starts fertility and reduces chances of abortions besides reducing other problems associated with PCOS.

Metformin/Glyciphage works primarily by suppressing hepatic glucose production, increasing glucose utilization in peripheral tissues. It may also reduce intestinal glucose absorption. Since it does not stimulate production of insulin, it does not cause hypoglycemia if used alone.
Rosiglitazone (Rezult) - work primarily by improving sensitivity to insulin in muscle and adipose (fat) tissue and also by inhibiting hepatic glucose production.
If hypoglycemia is experienced on either type of medication, it is most likely due to insufficient caloric intake, rather than a direct result of the medication. These medications may also help improve cholesterol and triglycerides levels, and may restore ovulation in premenopausal women with PCOS or diabetes.

Metformin hydrochloride (Glyciphage) - Gastrointestinal problems such as diarrhea, nausea, vomiting, abdominal bloating, flatulence and anorexia are the most common reactions. Usually the side effects are dose dependant and diminish over time. Starting with a low dose and building up to the desired maintenance level may help. The biggest risk, though very rare (1 in 33,000), of Metformin is the possibility of lactic acidosis (a buildup of lactic acid in the blood).
Rosiglitazone maleate (Rezult) - The most commonly reported side effects include upper respiratory tract infection and headache. It may reduce effectiveness of oral contraceptives.

The maximum recommended dose of Metformin is 2550 mg per day (3 x 850 mg pills). Studies with Metformin for patients with PCOS usually use 500 mg three times a day or 850 mg twice daily.

No, all women with PCOS don't suffer from Infertility but about 50% do, especially if they have delayed or no periods.

Yes, but the reasons for this happening are poorly understood. Some women seem to have a regular bleed regardless of ovulation, so one should look beyond cycle length to determine ovulation.

Step Approach

If BMI is elevated loss of at least 5% of current body weight
Ovulation induction with clomiphene (glucocorticoid if elevated DHEA-S)
Insulin sensitizer as a single agent
Insulin sensitizer in combination with clomiphene
Gonadotrophin therapy and IUI
Insulin sensitizer in combination with gonadotrophin therapy with IUI
Androstenedione
Laparoscopic Ovarian Drilling
IVF

Yes. Because of the tendency for women with PCOS to produce many small follicles, the trick to avoiding hyperstimulation is getting a few follicles to mature without an army of smaller ones. Caution should be used with medications, starting at the lowest doses, and follicle production should be monitored by ultrasonography and estradiol levels. It is possible that the use of Metformin with gonadotrophin induced ovulation may reduce the risk of hyperstimulation.

The purpose is to reduce androgens and restore menses. It is done as a day care laparoscopic procedure. A small needle is used to make 4 punctures in the ovary. An electric current at 40 watts is passed through the needle for 4 secs. Often a small amount of cyst fluid can be seen escaping as the puncture is made. Spontaneous ovulation resumes following the drilling and the chances of conception in the next 6 months are very high.
Surgical therapy for PCOS should not be considered as a first step in treatment in part because it is unclear what the long-term effects might be. A good time to consider it would be when making preparation for a diagnostic laparoscopy or considering in vitro fertilization.

Advantages of Metformin are

Regularizes periods
Enhances fertility
Reduces chances of abortions
Helps reduce weight
Reduces excess hair growth (though it takes a long time)
Reduces hair fall and acne
Prevents the complications of PCOS like Diabetes and Uterine Cancer

Although there was a fear earlier that insulin sensitizing medications taken during pregnancy would harm the baby, recent studies have all shown that these drugs are perfectly safe to use in pregnancy. In fact not taking them greatly increases the chances of abortions.

Many women with PCOS are insulin resistant, and pregnancy tends to be a time of increased glucose intolerance as well. When one combines the two, there is an increased incidence of gestational diabetes.

There is no cure for PCOS, but some women do have a normalization of cycles after a pregnancy. Those who had fertility problems may find it easier to get pregnant again.

There are a certain variety of pills now available in the market which contains some special ingredients like cyproterone acetate which are perfect for women with PCOS. They not only provide contraceptive benefit but also are given to adolescent girls for treatment of excess facial hair and acne. Women can take heart in the fact that it also gives a certain glow to the face.

At present, there is no cure for PCOS. The endocrine upset characterized by polycystic ovaries does not go away just because the ovaries are removed. Attention must be focused on why the ovary acted that way, and what signals called it to make 30 pellet-sized follicles at the same instant? It is possible that it might lessen symptoms, but it is a rather extreme approach that will not prove to be a cure.

There is very little information in medical journals about PCOS beyond the childbearing years. Right now the best recommendation is to monitor cholesterol, triglycerides, blood pressure, and glucose/insulin levels as one might for Syndrome X, and treat any minor abnormalities with diet and exercise, and more substantial alterations with medication.

In some ways, this question is akin to asking, "Which came first, the chicken or the egg?" since it isn't completely understood, but it appears more likely that PCOS comes first. Symptoms of PCOS may be lessened by weight loss, or increased by weight gain, but the syndrome is not caused by weight or body mass but it is definitely aggravated by it. There are lean women with PCOS. The insulin resistance that is common to PCOS may play a role in weight gain and the difficulty in losing any extra weight.




11th December, 2011
The Telegraph, Kolkata
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