Every 6th girl suffers from PCOS (Polycystic ovarian syndrome), its incidence being 10 to 15%. The polycystic ovarian syndrome is also known as Stein Leventhal syndrome is a complex hormonal disorder causing enlarged ovaries with small cysts on the outer edges, numerous genetic and environmental factors act and contribute to its pathophysiology through the actual aetiology (cause) is unknown. It is mainly characterised by Amenorrhea, Oligomenorrhea, Infertility, Irregular Cycles, Hirsutism & Obesity due to insulin resistance.
Clinical manifestation of PCOS
Growth of access terminal hair(thick, coarse male pattern type) due to the hyperandrogenism.
Androgen is converted into oestrogen(in Adipose tissue) which is an Irreversible reaction and more oestrogen is produced in the body which leads to a decrease in the fish and LH levels due to the negative feedback mechanism.
LH: FSH ratio normally which is 1:1, gets changed into 3:1 in PCOS
Increased LH causes thickening of Strome which in turn releases more Androgen.
(And Androgen—> Estrogen, and the cycle repeats)
Increased Androgen causes
Increase in Serum Testosterone and Androstenedione which leads to decrease in sex hormone-binding globulins and hence the number of free Androgens increases leading to Hirsutism.
A score of 1 to 4 is given for nine areas of the bodybody as shown in the image.
A total score less than 8 is considered normal,
A score of 8 to 15 indicates mild hirsutism,
A score > 15 indicates moderate or severe hirsutism.
A score of 0 indicates absence of terminal hair.
Second most common manifestation doesn’t respond to usual treatment, scarring in nature.
Less glucose in ovary leads to less energy and hence follicles do not grow leading to anovulation, female comes with complaints of infertility.
There is no Corpus luteum, hence decrease in the progesterone therefore complaints of metrorrhagia and oligomenorrhea( less than 8 cycles per year) or secondary amenorrhea.
Insulin Resistance(50-75% cases)
Decreased sex hormone binding globulin: increased ovarian androgen production by potentiating action of LH. More commonly seen in Obese PCOS female. Leads to increased glucose: inflammatory response (increase in the C reactive protein)
Abnormal OGTT (oral glucose tolerance test).
Acanthosis Nigricans: darkly pigment in skin seen typically at the Nape of neck.
Hyper Androgemism (HA)
Insulin Resistance (IR)
Acanthosis Nigricans (AN)
Thinning hair due to the effects of male hormones (androgens) is called androgenic alopecia. It is a major source of psychological distress to women. This male-pattern hair loss is often seen in women with polycystic ovary syndrome (PCOS)
Dyslipidemia: Studies suggest that if you have PCOS, you may be at a higher risk of developing abnormal lipid levels, too. It is estimated that up to 70 per cent of women who have it may also experience some degree of elevated cholesterol and/or triglyceride levels.
PCOS is associated with high rates of glucose intolerance resulting from defects in insulin action and β-cell function. Obesity substantially exacerbates these defects so obese reproductive-age women with PCOS are at very high rates of glucose intolerance.
Anxiety & Depression
PCOS is also associated with inflammation throughout the body. Prolonged inflammation is associated with high cortisol levels, which increases stress and depression. High cortisol also increases the risk of insulin resistance, which in turn can cause depression.
Rotterdam PCOS Diagnostic criteria
Presentation of the two out of three(2/3) criteria is sufficient to diagnose PCOS
1.Menstrual cycle abnormalities Amenorrhea &/ Oligomenorrhea
2.Clinical and biochemical hyperandrogenism
3.Ultrasound appearance of polycystic ovaries after all other diagnosis are ruled out.
Some normal women have just an appearance of cyst in ultrasound without any other symptoms this may not be termed as PCOS
Volume more than 10 CC
Follicle size 2-9mm
Number more than 20- 25
Stroma volume and echogenicity increases
In ovary, dominant follicle is not considered but only small follicles(2-9mm) in the Periphery a term that string of Pearl appearance.
Management of PCOS
- Weight loss should be advised to all patients.
- There is no single drug for PCOS but rather symptomatic approach is done.
- Irregular periods and not planning for pregnancy: OCP and progesterone support in the latter half of the month.
- Planning for pregnancy (ovulation induction) : letrozole clomiphene citrate and metformin
- Irregular periods + Hirsutism:
- OCP with ciproterone acetate.
Complications of PCOS
1. Short term complications of PCOS
- Irregular Cycles
2. Long term complications of PCOS
- Coronary artery disease(CAD),
- Dyslipidemia- Metabolic X syndrome,
- Endometrial hyperplasia increased risk of endometrial, ovarian, breast carcinoma.
- Due to obesity: Sleep apnea, Depression, NASH(Non-Alcoholic SteatoHepatitis).
- Diabetes Mellitus.
3. Complications in pregnancy due to PCOS
- Abortion/stillbirth (due to low progesterone levels):A stillbirth is the death or loss of a baby before or during delivery.
- Gestational Diabetes: a condition characterized by an elevated level of glucose in the blood during pregnancy, typically resolving after the birth.
- Preeclampsia: a condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and proteinuria.
- Preterm labor: labor that starts before term (37 weeks of pregnancy).