Polycystic ovarian syndrome (PCOS) is a gynaecological condition characterized by chronic anovulation (infrequent or absence of ovulation), hyperandrogenism (elevated male sex hormones) and polycystic ovaries (presence of several follicular cysts in the ovaries). At least two of these characteristics are required to make a diagnosis. PCOS is one of the commonest causes of irregular menstrual cycles and infertility in women. Also, PCOS is almost always associated with other metabolic disorders such as obesity, diabetes and cardiovascular diseases.
Women with PCOS often complain of irregular menstruation as this is the most evident symptom. Some experience scanty menses while others see their menses only 2 to 3 times per year. This also results in fertility issues because pregnancy cannot occur without ovulation. Normally, the lining of the uterus is shed every month (average of 28 days) in the absence of pregnancy. When there is no ovulation, the lining stays intact and continues to grow because of the imbalance in the hormones responsible for breaking the cycle (progesterone and oestrogen). Untreated anovulation can lead to endometrial hyperplasia and cancer later in life.
Every woman has a balanced amount of male and female sex hormones in the blood. PCOS causes an increase in the male hormones – androgens/testosterone. This results in virilization- hirsutism, deep voice, broad shoulders and acne. It’s important to rule out other causes of virilization such as hermaphroditism and other congenital anomalies.
According to the Rotterdam criteria, the ovary is said to be polycystic when it contains 12 or more follicles or measures more than 10 cubic centimeters. The diagnosis is based on a transvaginal ultrasound scan. This can present as lower abdominal pain but not always. These follicles mimic the normal follicles that produce the eggs and hormones, but they are ineffective and instead, produce excess androgens.
METABOLIC AND ENDOCRINE EFFECTS
As pointed out earlier, PCOS is strongly associated with obesity, diabetes, abnormal Lipid profile and cardiovascular diseases. Some can also have hypertension and obstructive sleep apnea manifesting as snoring and daytime somnolence. When patients get pregnant, they remain at risk of complications like gestational diabetes, hypertension and placental abnormalities. Hence, women with PCOS must be followed up, even after achieving regular menses or fertility.
After a detailed history and thorough physical examination, the diagnosis is almost always arrived at. We also need to do some test to confirm the diagnosis, determine the severity and identify coexisting metabolic disorders. These include:
-Hormonal profile: oestrogen, progesterone, testosterone, corticosteroids etc.
-Abdominal CT scan or MRI
-Blood sugar levels
The aim of treatment depends on the woman’s desire for fertility and concerns about virilization. In adolescents, we need to restore regular menses and treat hirsutism and acne. In married women, infertility is usually the main problem.
*Lifestyle modification and attainment of an healthy weight are the first line of management. As most patients are obese, weight reduction alone can be all that is needed to restore normalcy.
*Plucking, epilation creams and devices, waxing and laser therapy can be used to control hirsutism. Drugs like spironolactone can also be tried in resistant cases, but patients must be warned about side effects.
*Metformin is the first drug of choice. It helps to reduce all the symptoms of PCOS and also controls excessive weight and high blood sugar.
*Oral contraceptives help to regulate the menses in women who are not desirous of pregnancy any time soon.
*Ovulation induction is used for patients complaining of infertility after trying other conservative methods without success. This can be done medically (using clomephene citrate and other meds) or surgically (eg. ovarian drilling)
*Lipid-reducing medications and antihypertensives should also be considered if needed.
Regular follow up is essential to monitor progress and detect long-term complications such as diabetes, endometrial hyperplasia and cancer.