What is Polycystic Ovarian Syndrome?
Polycystic Ovarian Syndrome is Common Yet Neglected! In 1935, Stein and Leventhal were the pioneers to reveal the term Polycystic
Ovarian Syndrome (PCOS) in the medical literature. This syndrome has now
become more common and is affecting women throughout their life. PCOS is
an endocrine disorder whose presence is characterized by the elevated levels
of androgen (male hormones), irregularities in menstruation and formation of
small cysts in either or both the ovaries. Hyperandrogenism (excessive
in ideal indicator of the condition. These high levels prevent the follicle
development in ovaries causing their accumulation and finally forming a cyst.
With all this, it also negatively affects the endocrine, metabolic and cardiovascular
health. However, the clinical picture may vary among different individuals.
The prevalence of Polycystic Ovarian Syndrome varies with the diagnostic criteria. According to the
National Institute of Health, 6-10% of women within the reproductive age
group are affected with Polycystic Ovarian Syndrome. The commonness of the disorder was found to
be 9.13% in a study conducted among 460 girls of 15-18 years age group in India.
Women suffering from Polycystic Ovarian Syndrome often complain of menstrual disturbances that include
oligomenorrhea, amenorrhoea and extended bleeding days. These complaints stand
true as a report claims that 85-90% women with oligomenorrhea and 30-40% with
amenorrhoea have a chance of getting PCOS. It even remains a major cause of infertility
due to anovulation, 90-95% women with anovulatory condition suffer from PCOS.
How does polycystic ovary syndrome occur?
PCOS occurs due to complex events. It has multifaceted
mechanism to explain its physiology that
includes uncontrolled ovarian steroidogenesis (abnormal production of steroids),
insulin resistance, oxidative stress and other environmental factors.
Ovarian steroidogenesis demands stimulation by the Gonadotropin Releasing
Hormone (GnRH), in the hypothalamus which is further responsible for the release
of Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH). Luteinizing Hormone stimulates
ovarian thecal cells to synthesize androgens whereas the granulosa cells aromatize
androgens into estrogen due to Follicle Stimulating Hormone. Normally, in case of adequate levels, the ovarian
hormones (especially progesterone) send a negative feedback to inhibit the release of
GnRH stimulated hormones, whereas low levels of ovarian hormones
excite the release of GnRH by positive feedback mechanism. In Polycystic Ovarian Syndrome,
the GnRH becomes resistant to ovarian negative feedback, resulting in
increased Luteinizing Hormone production and decreased production of Follicle Stimulating Hormone. Due to these high Luteinizing Hormone levels,
thecal cells continue to produce androgens whereas inadequate Follicle Stimulating Hormone hinders the
aromatization of androgens into estrogen.
Complete Female hormone Tests
PCOS is associated with insulin resistance
(i.e. elevated levels of insulin). As insulin regulates ovarian function, ovarian thecal
cells responds to excessive insulin by the production of androgens. Hyperinsulinemia
also increases the levels of testosterone (androgen) by inhibiting the synthesis of
Sex Hormone Binding Globulin (SHBG). Intrinsic defect in the thecal cells also result
in hyperandrogenism. This internal dysregulation causes granulosa cells to produce
4 times higher number of anti mullerian hormones when compared to the normal cases.
Additionally, oxidative stress is known to induce
insulin resistance and hyperandrogenism in PCOS affected women. Genetic
component such as PCOS-susceptible loci and family history of Polycystic Ovarian Syndrome are also
potent factors in the occurrence of this syndrome.
What is the cause of polycystic ovary syndrome?
Exact cause of the syndrome is not known.
But, several factors that trigger the onset of PCOS in early age are as follows:
High birth weight in girls
Central precocious puberty
The other general factors initiating the disorder are:
Family history of PCOS
What are the symptoms of PCOS?
PCOS is an hormonal disorder affecting women throughout the globe.
Its signs and symptoms may vary among individuals, the most common
ones are anovulation, elevated levels of androgens and polycystic
ovaries. The other signs and symptoms are mentioned below:
Increase in size of ovaries containing cysts
Irregular menstrual cycle
Pain in the pelvic area
Abnormal uterine bleeding
What is the main cause of PCOS?
Although many factors provoke Polycystic Ovarian Syndrome, but it itself remains
a risk factor for many other clinical conditions such as:
Both obesity and PCOS, are interlinked, each being an independent triggering
factors of the other. It is reported that 80% of women affected with PCOS are overweight
and obese. This is because of the fact that high androgen levels increase the distribution
of fat in the visceral and subcutaneous layer making a person more obese. They also show
elevated levels of low density lipoprotein, triglycerides and cholesterol along with the low
levels of high density lipoprotein, worsening ones cardiovascular health.
PCOS induces metabolic disturbances. Insulin resistance is a crucial
pathogenic factor in PCOS affected women. Clinical report states that 30-40% women with
PCOS suffer from insulin resistance and solely 10% have type 2 diabetes mellitus.
Other studies reports that 85% of patients have hyperinsulinemia. This can be well explained
by the fact that increased levels of insulin along with high LH levels, hinders the follicular
development leading to anovulation. Increased insulin levels also alter the GnRH releasing
frequency and suppress the Sex Hormone Binding Globulin resulting in the over production of androgen, a general
clinical sign observed in Polycystic Ovarian Syndrome. A correlation exists between diabetes and PCOS, where
management of insulin levels reduces the levels of androgens thereby aiding in the
improvement of Polycystic Ovarian Syndrome as well. It is recommended for PCOS patients to detect insulin
resistance according to the Diabetes Prevention Program (DPP).
According to the 2015 study, infertility is 10 times common in Polycystic Ovarian Syndrome cases when
compared to the normal individuals. As the disorder is associated with endocrine
abnormalities, the quality of the ovaries and its function is significantly affected.
Other reports suggest that Polycystic Ovarian Syndrome women who conceive a child later may develop
gestational diabetes and can show pregnancy related complications.
It also increases the risk of miscarriages in women affected with PCOS.
As PCOS harbors many risk factors such as obesity, insulin resistance, infertility and
anovulation, the risk of endometrial cancers increases drastically. Anovulation stimulates an
unopposed estrogen exposure, which results in the development of endometrial hyperplasia
and finally ending in endometrial cancer. The thickening
of the endometrium seen in Polycystic Ovarian Syndrome, is a risk factor for the onset
of endometrial cancer.Additionally, studies report that PCOS
increases the risk of endometrium cancer by three fold.
PCOS is also known to increase the risk of myocardial
infraction by 7 times. It significantly increases the levels of markers of CVD like
C-reactive protein and lipoprotein A. polycystic ovary syndrome (PCOS) also causes arterial stiffness,
endothelial dysfunction and coronary artery calcification which are prominent
risk factors of atherosclerosis.
Stress is one of the common disorders associated
with Polycystic Ovarian Syndrome. It brings about anxiety, eating disorder and psychosexual dysfunction.
PCOS affected women tend to have a low self-esteem and dissatisfaction of their
body when compared to the healthy women. They are also prone to a high degree
of emotional distress. The signs of Polycystic Ovarian Syndrome like obesity, hirsutism, acne also contribute
to the psychological stress due to the social pressure.
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What tests are done to diagnose PCOS?
Different criteria have been given by different organization to diagnose
PCOS. The first was given by National Institute of Child Health and Human Development
(NICHD) in 1990. Later after 10 years, the experts realized that morphology of the
ovaries were a key component in the diagnosis of PCOS, accordingly the European
Society of Human Reproduction and Embryology (ESHRE) along with American Society
for Reproductive Medicine (ASRM) in Rotterdam modified the first criteria and added
pelvic ultrasound to check the morphology of ovaries as one of the criteria. In 2006,
the Androgen Excess Society (AES) concluded that the first criteria can be used along
the modifications by the Rotterdam's criteria.
For suspected women, a previous medical history, physical examination,
blood tests and an ultrasound is suggested. Physical examination
and medical history enables the physician to know about the sudden weight
gain, abnormalities in menstrual cycle, male pattern hair growth, skin changes and rise in blood
pressure. The blood tests check for the levels of hormones, glucose and lipids whereas an
ultrasound detects the presence of cysts in the ovaries.
As studies have claimed that 50% of Polycystic Ovarian Syndrome develop other comorbidities
mentioned above, the individuals should be informed about the same.
Even pregnant women must be made aware about the increased rates of
miscarriages, gestational diabetes and premature delivery.
What is the most effective treatment for PCOS?
Managing the disorder can be done by treating the symptoms
such as obesity, acne, hirsutism and anovulation. As the cause of disease
remains unknown, managing the symptoms may provide ease.
It is recommended to restrict calorie intake and follow exercise regimen to prevent the
obesity, a prominent risk factor for Polycystic Ovarian Syndrome. A study suggest that decrease in body weight
even by 5% can help in regulating irregular menstrual cycles, improves fertility and
reduces the levels of insulin and testosterone?? and decrease the acne and hirsutism.
However, if lifestyle changes are not bringing in positive review, then regular checkups
and seeking medical supervision is recommended.