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Polycystic Ovary Syndrome

Overview

Polycystic ovary syndrome, commonly called PCOS, is a condition in which ovaries have multiple small cysts (fluid-filled sacs), and the ovaries produce excessive androgens (male hormone). Females may present with irregular periods, weight gain, infertility, and male pattern hair growth. Although not life-threatening, PCOs adversely affect endocrine, metabolic, and cardiovascular health. The ovary fails to release eggs and may result in infertility. PCOs may sometimes lead to peritonitis upon rupture or torsion.

Causes

Although the exact cause is unknown, a genetic link is suspected; the disease is thought to result from a genetic mutation in autosomal chromosomes that causes enzymatic disturbance in the ovary. Among environmental factors, obesity and insulin resistance have been researched the most. Increased insulin levels disrupt the normal hypothalamus-pituitary axis, which is the control center for sex hormones resulting in hormonal imbalance in females. Fat tissue in obese women provides the source of substrates for androgens production. 

Risk Factors

 Risk factors for Polycystic Ovary Syndrome (PCOS) include:

  • A family history of infertility
  • Mother’s irregular menstruation (Period)
  • Diabetes ( type 1 or type 2)
  • Gestational diabetes 
  • Insulin resistance (insulin is a hormone produced in the pancreas that allows cells to use sugar, the body’s primary supply of energy) 
  • The trouble with weight loss or weight gain are also risk factors for PCOS; many doctors associate the syndrome with weight problems. 

Epidemiology

In the U.S, PCOS is very common, with a prevalence of 4- 12% in women of reproductive age. PCOS is higher in South Asians and Hispanic women. According to (WHO) World Health Organization, PCOS has affected 116 million women worldwide.

Signs And Symptoms

Signs and symptoms of PCOs are related to menstrual abnormalities, anovulation, and increased male sex hormone levels. The patients usually present to the clinics when they are young. 

The most common complaints are:

  • Menstrual irregularity; missed period, light or heavy period, secondary amenorrhea (absence of periods) 
  • Hirsutism (excessive body hair), especially around the belly, is a common clinical presentation of hyperandrogenism 
  • Weight gain
  • Insulin resistance and hypertension.
  • Male pattern baldness, thinning of hair, and seldom bleeding per vagina due to rupture of the cysts
  • Miscarriage
  • Spontaneous abortion   
  • Approximately 15 -20% of women present with acne and oily skin  
  • Small pieces of excess skin tags on neck and armpits 
  • Dark skin patches on neck, armpits, and under breasts
  • Obstructive sleep apnea (a condition marked by momentary pauses in breathing)  
  • Dull abdominal pain or severe pain when the cysts rupture 

Diagnosis

Your health care provider will begin with a detailed medical history and physical examination, including a pelvic exam. The triad usually considered as diagnostic includes the presence of multiple cysts on ultrasound, obesity, and hirsutism. You may be advised to undergo some of the tests, which include;

  • Blood tests: Blood tests to measure hormone levels such as LH, FSH  (the ratio is changed 3:1), blood glucose, cholesterol, triglycerides, Serum prolactin level, Thyroid function tests, Total and free testosterone levels, Serum insulin-like growth factor (IGF)–1 level.
  • Ultrasound pelvis: There is a typical appearance of multiple small cysts known as String of pearls on ultrasound. This is seen in 80% of patients. If the ovaries appear polycystic on ultrasound without any clinical features, it is called Polycystic Ovaries. On the other hand, if there are other features along with polycystic, such as menstrual irregularity and infertility, then it is called Polycystic ovarian disease. 
  • You might be screened for anxiety along with depression and Obstructive sleep apnea. 

Differential Diagnosis

Some other disorders, like PCOs, may present and must be ruled out to make an efficient diagnosis.

  • Hypothyroidism or hyperthyroidism
  • Hyperprolactinemia
  • Congenital adrenal hyperplasia
  • Ovarian tumors
  • Cushing’s syndrome
  • Use of Exogenous anabolic steroids
  • Use of some drugs (e.g., androgenic progestins, danazol)

Treatment

The baseline treatment is controlling weight via a diet plan and initiating exercise. Hormonal contraceptives are considered first-line treatment for menstrual abnormalities and hirsutism/acne. Oral contraceptives such as norethindrone, norgestimate, or desogestrel, are most commonly used.  Metformin is advised to deal with insulin resistance. While dealing with an infertile patient, clomiphene citrate or gonadotropins are given. 

Other medicines may include Antiandrogens, Prednisone, Leuprolide, Spironolactone.

Simple cysts are known to self-cure or reabsorb spontaneously. Sometimes, such cysts are found incidentally during surgery or pelvic examination. They are managed best by being left alone, as even after incision, they can re-occur in younger women.

In cases of resistance, laparoscopic ovarian diathermy is advised. Resection is also recommended for cysts that persist and grow larger than 8cms. 

Prognosis

Women suffering from PCOS not only have implications on their reproductive health, but such patients are also at risk of type 2 diabetes, inflammation, and heart disease later in life. PCOS increases the risk of certain cancers, such as endometrium cancer.

Insulin resistance leads to many comorbidities such as hypertension, glucose intolerance, dyslipidemia, and diabetes. If left untreated, patients are at an increased risk for stroke.

One should consult a doctor and receive treatment accordingly.

Lifestyle Modification

Lifestyle changes are considered the cornerstone of PCOs treatment. One must adopt the following habits to cope with PCOs;

Moderate regular exercise: It has many benefits. It helps burn calories and builds lean muscle mass, decreasing insulin resistance. Exercise also helps lower cholesterol levels.

You may consult a nutritionist to help reduce weight, maintain a healthy balanced diet, or use calorie–counting aids. 

Paying attention to portion size and cutting down the excessive intake of sugars and carbohydrates is essential. This will improve fertility and PCOS outcomes and reduce the risk of diabetes, metabolic syndrome, and other complications that result from having untreated PCOS.