Understanding Polycystic Ovary Syndrome (PCOS)

WHAT IS PCOS?

Polycystic ovary syndrome, or PCOS, is a common condition that affects the functioning of the ovaries. Normal functioning of the ovaries involves regular maturation and release of an egg from either of the ovaries, called ovulation, which happens once in 28 days on an average, and is a result of cyclical changes in the levels of certain hormones released from a gland called the pituitary, that resides inside the brain. Regular ovulation translates into regular periods, acting through cyclical changes in hormones released from the ovaries. These delicately controlled hormonal cycles can often get disrupted and can cause a wide range of symptoms.

SYMPTOMS AND PRESENTATION

1. Irregular periods due to irregular or absent ovulation, which could be

• delayed periods
• prolonged absence of periods
• unpredictable periods

2. Excess of male hormones (androgens) in the body which may cause:

• increase in body hair (coarse hair on the face, chest, abdomen, or upper thigh referred to as hirsutism)
• hair fall sometimes leading to male pattern baldness
• oily skin, or severe acne that is not associated with adolescence and is not responding to usual treatments.

3. Polycystic ovaries: The ovaries may become enlarged and contain multiple fluid-filled sacs called cysts, which are harmless underdeveloped nests (follicles) in which the eggs grow before ovulation. In PCOS, the follicles may fail to develop fully, mature, and regularly release the eggs, hence resulting in irregular ovulation, leading to irregular periods.

The presence of any 2 of the above 3 is diagnostic of PCOS in adults. However, in adolescents, polycystic ovaries may be a common physiological finding.

An increase in weight and inability to lose weight is often observed, and the PCOS symptoms tend to be more severe if the woman is overweight or obese. Psychological issues often accompany the symptom complex.

CAUSES

The exact cause of PCOS is not clear. Hormonal imbalance associated with an increase in the level of androgens (male hormones) over and above the small amount that all women have, prevents regular ovulation and gives rise to the other symptoms.

A condition called insulin resistance (where the body does not respond well to the glucose-handling hormone insulin) is seen in a majority of women with PCOS. When the body cells become resistant to insulin, blood sugar levels rise, and the body responds by producing more insulin. Excess insulin increases androgen production which causes the symptoms. Obesity and weight gain can aggravate insulin resistance.

Occasionally, excess androgen production from the ovaries or adrenal gland might be the cause of the condition.

There might be some genetic association as PCOS often runs in families.

DIAGNOSIS

The symptoms of PCOS can wax and wane, especially if the woman’s weight keeps fluctuating. Essentially, just the ultrasound appearance of the ovaries does not call for a diagnosis of PCOS. A detailed history of the duration and severity of symptoms, and physical examination, coupled with the findings of the ultrasound scan, and blood tests are helpful in reaching a diagnosis. The usual blood tests that are done include hormonal levels, blood sugar levels, insulin levels, lipid profile, hemoglobin, blood counts, and tests to rule out thyroid dysfunction.

HEALTH IMPACT AND COMPLICATIONS

PCOS can increase the risk of developing many more serious conditions with lifelong consequences along with having a visible impact on the appearance of the woman. These conditions include:

1. Infertility or inability to conceive as a result of irregular or absent ovulation
2. Diabetes and high blood pressure during pregnancy.
3. Metabolic syndrome, which is the name given to a symptom complex involving high blood pressure, high blood sugar levels, and abnormal lipid profile, are factors increasing the risk of cardiovascular disease.
4. Type 2 diabetes or pre-diabetes
5. Sleep apnea
6. Depression, anxiety, eating disorders, and other psychological issues
7. Abnormal bleeding patterns
8. Endometrial hyperplasia (abnormal thickening of the uterus lining) which in turn is associated with a heightened risk of developing endometrial cancer (cancer of the uterus lining)

TREATMENT

Even though there is no absolute cure for PCOS, all the symptoms can be treated and the condition controlled.

Diet and Lifestyle

If overweight, weight loss by means of dietary management and regular exercise can help. Reducing weight helps not only by causing ovulation and periods to become regular, but also by making a positive contribution towards insulin levels and the body’s efficiency of using insulin, and thus helps in bringing down the androgen levels. Even in normal-weight individuals, a healthy lifestyle comprising of a balanced-nutritious diet, optimum physical activity and exercise, stress management, and a regular sleep-wake cycle, can contribute towards normalizing the body milieu.

Medical treatment

It is tailored according to the symptoms and basically depends on whether or not pregnancy is desired. All medication should always be taken under the guidance, prescription, and monitoring of a qualified medical professional, preferably a Gynecologist.

If pregnancy is desired, medicines to induce ovulation (release of the egg) can be given.

If pregnancy is not desired, and irregular periods are a concern, birth-control pills (contraceptives) may be tried. They help in regularizing periods, reducing androgen levels, and may also help in reducing acne.

Medications for diabetes that is medicines or supplements to reduce insulin resistance are prescribed in both women who desire or do not desire pregnancy. These can help reduce the circulating androgens, which may translate into regular ovulation.

Chronic inflammation and disturbance of the gut bacterial flora may also contribute to insulin resistance, therefore probiotics may also be prescribed in some cases.

Cosmetic treatments can be individualized according to the severity of symptoms. For excessive hair growth, several medicines are available that can arrest the process. For hair that has already turned coarse, treatments are available to remove hair temporarily or permanently. Medications for acne can similarly be managed by a combination of local and systemic medications.

A psychological evaluation and appropriate counseling/medications may be recommended in select cases with evidence of clinical depression, anxiety, or other issues of mental health.

Outlook

In spite of the name, many women with PCOS may not have ovarian cysts. In those that do, the cysts themselves usually do not cause symptoms or problems, and usually do not require intervention.

Polycystic ovary syndrome need not be a dreaded diagnosis. The awareness of the hormonal imbalance in the body can and should be used to seek appropriate treatment where required and to bring about the lifestyle modifications that can go a long way in keeping the complications at bay, and in many cases, even rectify the hormonal imbalance and normalize the entire physiology.

Dr Jasmeet K Monga, MD (Obs & Gynae), DNB, FRCOG (UK) is Consultant Obstetrician & Gynaecologist at Clinic One, Gurugram, India. She specializes in providing personalized, ethical, up-to-date and evidence-based advice and care for women at various stages of their lives, right from adolescent health, contraception advice, pre-marriage and pre-conception counselling to fertility issues, pregnancy care, menstrual problems and menopausal health. www.clinicone.in

Also read:

Ovarian Cysts: Understanding Causes, Diagnosis and Implications

Female Infertility : Causes, Evaluation, and Management

Painful Periods: How to tackle Dysmenorrhea

Understanding and Tackling Premenstrual Syndrome (PMS)