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:
Obesity 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.
Insulin resistance 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).
Infertility 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.
Cancer 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.
Cardiovascular disease 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.
Psychological problems 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.Female Health Checkup starting @ Rs 700 Only
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.