Polycystic ovarian Syndrome (PCOS)

Polycystic Ovaries on Ultrasound

1. What is a polycystic ovary?

A polycystic ovary (Poly-multiple, cyst-fluid filled structure) is characterized by the presence of numerous, small (8-10mm sized) fluid filled structures all over its surface. This is in contrast to a normal ovary which may have none or 1-3 developing follicles in one menstrual cycle.

 Actually these fluid filled structures are immature eggs surrounded by fluid and are called follicles.

Polycystic Ovarian Syndrome is also known as Stein-Levinthal Syndrome (named after its discoverers)

Model of Polycystic ovaries

2. What is the cause of Polycystic Ovarian Syndrome? 

The final defect in PCOS is hormonal impairment. However the cause is now regarded as multifactorial. Insulin resistance, low grade inflammation and even an impairment of genetic expression in foetal life have been attributed to cause PCOS. Genetic factors (Higher incidence amongst siblings or mother-daughter-granddaughter), environmental factors (excessive weight), metabolic derangement (obesity and impaired glucose metabolism) are all postulated to contribute to the condition.

3. Why is PCOS important?

Ovaries are the reproductive organs responsible for producing eggs and the female hormones. Hence they are important for natural conception and regularity of menstrual cycle. In PCOS there is impairment of ovarian functions.

Thus it follows that in PCOS there is impaired production of eggs and hence associated menstrual and hormonal irregularities .This naturally affects not only the menstrual cycle of a woman but also her fertility.

PCOS is also associated with other medical conditions and long term effects as enumerated below.  

4. What is the incidence of PCOS in India?

PCOS is the most common hormonal reproductive problem in women of childbearing age. The incidence is believed to be on a rise in India. A modest estimate is that 7-10% of women in the reproductive age group (15-45 years) suffer from this condition. But in pracgice the incidence is noted to be much higher.

5. What are the features of PCOS?

Women may have varied features. These include:

a)      Irregularity in menstruation: Delayed cycles and/or scanty flow. Absent menstruation for several months or menstruation occurring only after hormonal therapy. Some women may have continuous flow following periods of absent menstruation.

b)      Excessive weight-Most PCOS patients are overweight or obese. However PCOS can occur in underweight women also.

c)      Facial hair, acne (pimples) and loss of hair from the temple region. These features are medically termed as hyperandrogenic features and are attributed to excess circulating male hormones. Acanthosis Nigricans is black discoloration of the nape of neck, axillae and under the breasts and is often indicative of insulin resistance.

d)     Inability to conceive: This results due to improper or absent production of eggs from the ovaries.

e)      Other hormonal impairments: PCOS patients often have impaired glucose metabolism which causes increased blood sugars. Levels of Prolactin (hormone secreted by the pituitary gland in the brain) may also be raised. LH (Luteinizing hormone, also secreted by pituitary) which is responsible for production of eggs is classically raised 3 times over its sister hormone FSH (Follicular Stimulating Hormone)-though this is no longer a required criterion for diagnosis.

f)       Ultrasound diagnosis: On ultrasound scan, the ovaries are classically enlarged with raised volumes and each shows over 10-12 clear follicles of 8-10mms. This is one of the latest internationally accepted criteria for diagnosis of PCOS. The other two are menstrual irregularities and features of androgenization (see c)

6. What are the long term consequences of PCOs?
      Patients with PCOS have inability to conceive. This is due to absent/unhealthy egg production and also because of the multitude hormonal derangements that occur in this condition.
      It is now established that patients with PCOS are prone to develop diabetes (non-insulin dependent or Type II diabetes), impaired lipid metabolism (Dyslipidemia) and ischaemic heart disease (reduce blood supply to heart causing heart attacks).The associated obesity is also a contributory risk factor to these conditions.
      Prolonged periods of absent menstruation and hence impaired levels of the female hormone, estrogen,           makes these women prone for osteoporosis (loss of calcium from bones) and its attended     complications.

PCOS patients are at an increased risk of developing cancers of the breast, endometrium (lining of

uterus) and maybe ovary at a later stage in life.
PCOS patients who conceive are believed to be at a higher risk for mis-carriages and pregnancy induced hypertension during their pregnancy.

Also the psychological impact of impaired menstruation, infertility, obesity, facial hair and acne cannot be under estimated though not completely quantified.

7. Can PCOS be treated?

      Yes, but not to complete satisfaction at times. It is very disappointing many a times because the patient, who got better with treatment, reverts back to impaired functioning a few months after medications have been stopped.

8. What are the modalities of treatment for PCOS?

a) Lifestyle modification:

 As obesity is one of the features and a contributory factor to PCOS, it helps greatly if patients strive to reduce weight. Even a modest weight reduction of 4-5 kgs works wonders as patients begin to respond better to treatment. It is advisable to maintain your BMI (Body Mass Index, which is calculated based on height and weight of an individual) between 20 and 25. 

b) Medical treatment:

Treatment of PCOS needs to be tailored to suit each patient. It depends upon the main complaint of the patient and her requirements. For a 20 year old, the problem could be of acne and irregular periods; and for a married woman it could be inability to conceive and for many others their irregular cycles or facial hair may be disconcerting.

Options available are

• Oral contraceptive pills: A wide variety of combinations are available to suit the needs of every patient depending on her symptoms. Oral Pills regularize the cycles, correct the underlying hormonal problems to some extent and offer contraception to those not wanting to conceive. For women desiring to conceive, oral pills are offered for a few months before starting treatment.
•  Drugs for treatment of infertility: Clomiphene citrate is a drug which induces the formation of eggs from the ovary. It may be used alone or in combination with hormonal injections like the hCG (Human Chorionic Gonadotropins) or hMG (Human Menopausal Gonadotropins) or FSH (Follicle Stimulating Hormone) or GnRH (Gonadotropin Releasing Hormone analogues) These medications are used to aid the formation and release of eggs and hence help achieve pregnancy.
•  Metformin: This is often used in the treatment of mild diabetes. Since PCO is associated with impaired glucose metabolism, metformin helps to correct the underlying impairment. Dosage for PCOs: 1500mgs/day in divided doses.
•  Co-therapies: Medications to reduce weight (orlistat) are used in obese patients, medications and mechanical methods (laser, electrolysis, waxing) are employed for patients with facial hair. Oral pills which contain Cyproterone Acetate help in clearing the face of acne while those with Drosperinone may reduce rate of facial hair growth.

c) Surgical treatment: The multiple cysts present on the ovaries are punctured to let out the ‘unhealthy’ follicular fluid by a key-hole surgical procedure called Laparoscopic Ovarian Drilling (LOD). Around 4-6 punctures are made in each ovary. This procedure improves the internal environment of the ovaries and also makes them more responsive to drugs during the future course of treatment.

LOD (Laparoscopic Ovarian drilling)

9) What is PCOS in a nutshell?

•   PCOS is quite a common condition with a wide variety of manifestations.
•  The exact cause of PCOS is still not yet established. It could be familial.
•  PCOS needs to be treated as they have current and long term consequences for a woman.
•  The treatment of PCOS is to be tailored to an individual and may span several months.
•  Any ovary with cysts is NOT a PCOS. It has set criteria to be satisfied and you need to consult the specialist.