PCOS or Polycystic Ovarian Syndrome – an Overview

polycystic ovarian syndrome

PCOS or Polycystic ovarian syndrome and polycystic ovaries are two different conditions which are often used synonymously.

Polycystic ovaries refer to a condition in which at least one of the ovaries contain twelve or more follicles. Thus polycystic ovary is a radiological diagnosis.

In contrast to polycystic ovaries, the polycystic ovarian syndrome is a triad of

    1. Oligo-ovulation or anovulation (manifested as infrequent or absent menstrual cycles)
    2. Clinical or biochemical evidence of excess androgens (male hormone – testosterone) in the body
    3. Polycystic ovaries

What causes a polycystic ovarian syndrome?

The exact pathogenesis of polycystic ovarian syndrome is not clear but multiple factors including genetics play their roles. PCOS is the most common endocrine disorder in women between 18 and 44 years of age.

Females with the polycystic ovarian syndrome have a maternal history of oligomenorrhea and their fathers have excessive body hair.

What are the symptoms of Polycystic ovarian syndrome?

clinical features of PCOS

The major defect in PCOS is the imbalance of androgens and estrogens. When androgens are in excess, females tend to develop excess facial hair, deep voice, masculine features, and menstrual irregularities.

The other hormonal abnormalities associated with PCOS are increased insulin (hyperinsulinemia) in the body, increased insulin resistance in the body leading to diabetes, abnormal fat metabolism (dyslipidemia) and obesity.

More than 50% of females are obese and have metabolic syndrome. Metabolic syndrome is characterized by diabetes or pre-diabetes, hypertension or pre-hypertension, obesity, and dyslipidemia (triglyceride levels > 150 mg/dl and HDL <50 mg/dl).

Hypothyroidism is also a common occurrence in patients with PCOS. Patients may also present with excessive snoring, day time sleeping and features of obstructive sleep apnea.

Most patients are diagnosed when they present for evaluation of infertility. In fact, one of the most important causes of female infertility is PCOS.

How is PCOS diagnosed?

To diagnose PCOS, other causes of menstrual irregularities, infertility, and androgen excess should be ruled out first.

These studies, depending on the patients’ clinical features, include workup for thyroid disorders, acromegaly (excess growth hormone), androgen-secreting tumors, late-onset congenital adrenal hyperplasia, primary ovarian failure, and turners’ syndrome

Specifically, for PCOS, after the exclusion of other disorders, the following tests may be ordered.

Early morning blood testosterone levels, luteinizing hormone and Follicle stimulating hormone levels. Typically, in PCOS, LH: FSH is elevated three times or more.

Pelvic ultrasound and preferably transvaginal ultrasound should be performed to look for ovarian enlargement and the number of cysts in each ovary.

All patients should be investigated for diabetes and metabolic syndrome.

How is PCOS treated?

daily exercise is essential

Patients with PCOS should be advised to lose weight, exercise regularly, eat low caloric diets and quit smoking.

Pharmacologic treatments are reserved for the associated metabolic derangements, such as anovulation, hirsutism and menstrual irregularities.

    • Metformin is one of the first line and favorite drug of the gynecologists.  It reduces insulin resistance and is thought to reduce androgens in the body.

Metformin is also weight neutral and may cause weight loss in many patients. Patients who are pre-diabetics and those labeled as having diabetes, metformin is the drug of choice.

    • Physicians may also try GLP-1 agonists like liraglutide and dulaglutide which have a better weight loss profile and also reduce insulin resistance. Metformin is also said to reduce the risks of gestational diabetes, eclampsia, and pre-eclampsia.

    • Acne should be treated with topical or oral antibiotics and topical or oral retinoids

    • Hirsutism is treated with topical creams like eflornithine and laser therapy. Spironolactone, a potassium-sparing diuretic with anti-androgenic properties is also one of the drugs used to treat hirsutism.

    • Other than the above drugs, oral contraceptives can also be used to treat hirsutism.

Oral contraceptives with potent antiandrogenic properties should be used. These drugs, apart from being used to treat hirsutism, are also used to treat menstrual irregularities.

The most worrisome complication of PCOS is infertility.

Patients who wish to conceive should be advised low-calorie diet and a diet low in saturated fats, regular exercise, and weight loss.

The drug used as a first line for infertility is clomiphene citrate. Letrozole and gonadotrophins may also be used.

The use of gonadotrophins is associated with multiple pregnancies and ovarian hyperstimulation syndrome.

Lastly, gynecologists may try certain surgical procedures like ovarian drilling and the now less favorite procedure, ovarian wedge resection.

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