Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of
uncertain etiology, but there is strong evidence
that it can to a large degree be classified as a genetic disease.
PCOS produces symptoms in
approximately 5% to 10% of women of reproductive age (12–45 years old). It is
thought to be one of the leading causes of female subfertility and
the most frequent endocrine problem in women of reproductive age.
The syndrome is associated with numerous morbidities,
including infertility, obstetrical complications, type 2 diabetes mellitus,
cardiovascular disease, and mood and eating disorders.
Etio-Pathophysiology
PCOS is a complex, heterogeneous
disorder of uncertain etiology but the element of genetics is more likely to be
involved.
The
pathophysiology of PCOS is not well understood, mainly due to lack of knowledge
of the location of the primary defect. There are several candidates: ovary,
adrenal, hypothalamus, pituitary, or insulin-sensitive tissues.
Investigations have elucidated some of the interactions between
these systems.
·
Insulin resistance leads to compensatory
insulin hypersecretion by the pancreas in order to maintain normoglycaemia.
·
The resulting hyperinsulinaemia promotes
ovarian androgen output and may also promote adrenal androgen output.
·
High
insulin levels also suppress hepatic production of sex hormone binding globulin
(SHBG), which exacerbates hyper-androgenaemia by increasing the proportion of
free circulating androgens.
·
Another factor that promotes ovarian androgen
output is the fact that women with PCOS are exposed long term to high levels of
LH. This LH excess seems to be a result of an increased frequency of
gonadotrophin-releasing hormone (GnRH) from the hypothalamus.
The overall abnormal hormonal picture also probably contributes to incomplete follicular development which results in polycystic ovarian morphology.
Sign
Symptoms
- Absent
or infrequent periods
(oligomenorrhoea):
usually only occur once or twice a year
- increased
facial and body hair (hirsutism): usually found under the chin, on the
upper lip, forearms, lower legs and on the abdomen (usually a vertical
line of hair up to the umbilicus)
- acne: usually found only on the face
- Subfertility/
infertility: infrequent or absent periods
are linked with very occasional ovulation, which significantly reduces the
likelihood of conceiving
- overweight
and obesity: a common finding in women with
PCOS that occurs due to insulin resistance which prevents peripheral glucose utilization
by the cells and thus glucose is stored as adipose tissue.
- miscarriage. one of the hormonal abnormalities in PCOS, a raised level of luteinising hormone (LH - a hormone produced by the brain that affects ovary function), seems to be linked with miscarriage. Women with raised LH have a higher miscarriage rate (65 % of pregnancies end in miscarriage) compared with those who have normal LH values.
Risk Factors
- Obesity
- Anxiety/ Depression
- Epilepsy: Both epilepsy and the use of anti–seizure medications increase the risk of PCOS.
- Family History: Approximately 40 percent of first–degree relatives are affected.
Diagnosis
- For diagnosis, two of the following three criteria should be met, and other diseases with similar symptoms should be ruled out:
- Menstrual irregularity: Lack of periods, decreased frequency of periods, or irregular bleeding may all occur.
- Signs of increased androgen hormones: This may appear as hirsutism, acne, male–pattern baldness, or elevated testosterone concentration in the blood.
- Polycystic ovaries, visible on transvaginal ultrasound:
The cysts (fluid filled sacs) in the
ovaries can be identified with imaging technology. Ultrasound imaging is
commonly for diagnosis.
- Several blood tests are necessary to evaluate the effects of the disease, including measurements of various hormones, blood glucose, and insulin.
- Because coronary artery disease is common in patients with PCOS, cardiovascular risk factors should be evaluated (e.g., high cholesterol levels), and further testing may be necessary, such as an electrocardiogram and stress testing. Smoking should also be discouraged.
Treatment
- Weight loss, increased physical activity, and diabetes medications (e.g., metformin) are usually necessary.
- Oral contraceptives are used to regulate the menstrual cycle and protect the uterus in women who are not interested in becoming pregnant.
- Hirsutism is treated by hair removal and various medications, including oral contraceptive pills, anti–androgen medication (e.g., spironolactone), or gonadotropin–releasing hormone analogs (e.g., leuprolide).
- Acne is treated with topical or oral medications.
- Treatment of infertility is often necessary if the patient desires pregnancy. This may include medical therapies (e.g., clomiphene ormetformin) or assisted reproductive technologies (e.g., in–vitro fertilization).
