Polycystic Ovary Syndrome PCOS causes, diagnosis & treatment

Polycystic Ovary Syndrome PCOS is a condition that includes ovarian dysfunction along with cardinal features of hyperandrogenism and polycystic ovary morphology. With increasing consumption of processed food and a higher prevalence of obesity, Polycystic ovary syndrome PCOS is becoming a leading health issue. you must know the risk factor and causative agents of Polycystic ovary syndrome PCOS to take preventive measures and bring about lifestyle modification.

Obesity

  • Up to one-half of women with PCOS are obese, with an increased prevalence of abdominal or central obesity
  • Most women with PCOS are hyperinsulinemic (high level of insulin) and insulin resistant ( body receptors do not respond to insulin hormone)

Oligomenorrhea

Oligomenorrhea means infrequent or abnormally light periods.

  • Classically have a peripubertal onset
  • May have regular cycles at first, followed by irregularity and weight gain
  • Present in upto75% of patients, predominantly related to chronic anovulation

Hirsutism and Virilization In Polycystic Ovary Syndrome

  • Excess body hair in a male distribution
  • Male pattern balding
  • Deeper voice, muscle mass, clitoromegaly
  • Subfertility in up to 75% of women
  • Recurrent miscarriage in around 50-60% of women
  • Acanthosis nigricans- skin discoloration
  • May be asymptomatic

NIH Criteria

  • 1990 Consensus
    • Menstrual irregularity due to oligo/anovulation
    • Evidence of hyperandrogenism
    • Exclusion of other causes of the above two

 

Other causes:  neoclassic congenital adrenal hyperplasia (21-OH deficiency), Cushing’s syndrome, hyperprolactinemia, primary hypothyroidism, acromegaly, premature ovarian failure, simple obesity, virilizing adrenal or ovarian neoplasm, or drugs.

 

Rotterdam Criteria For PCOS

Requires the presence of two out of the following three variables and the exclusion of other disorders

  1. Irregular or absent ovulation(cycle>42 days)
  2. Clinical and/or biochemical signs of hyperandrogenism(Acne, hirsutism, alopecia)
  3. POLYCYSTIC OVARIES on pelvic ultrasound >=12 antral subcapsular follicles on one ovary <10 mm in diameter, Ovarian volume >10ml

Aetiology

The pathogenesis is not fully known

  • There is hypersecretion of LH in 60% of PCOS patients
  • Elevated LH: FSH ratio is often seen
  • Genetic
  • Insulin resistance with compensatory hyperinsulinemia
  • Hyperandrogenism
  • obesity

 

Examination

  • BMI
  • Signs of endocrinopathy
  • Hirsutism
  • Acne
  • Alopecia
  • Acanthosis nigricans

Investigations

  1.   dehydroepiandrostenedione (DHEAS)
  2.   Androstenedione
  3.   SHBG
  • Exclude other causes of secondary amenorrhea
  • Pelvic ultrasound

Management

  • Lifestyle modification
  • Improving menstrual irregularity
  • Controlling symptoms of hyperandrogenism
  • Subfertility
  • Insulin sensitizers
  • Psychological issues

Improving menstrual irregularity

  • Weight loss
  • Combined oral contraceptive pills (COCP)
  • Cyclical oral progesterone
  • metformin

Hyperandrogenism

  • Cosmetic
  • Antiandrogens
  • COCP
  • Cyproterone Acetate(anti-androgen contraceptive pill)
  • Metformin
  • GnRH analogues with low dose HRT: reserved for women intolerant of other therapies

Hyperandrogenism

  • Surgical treatment eg laser/ electrolysis
  • Spironolactone – antiandrogen properties

 

Subfertility

  • Weight loss
  • Ovulation induction with antiestrogens (eg clomiphene) or gonadotrophins
  • Laparoscopic ovarian diathermy
  • IVF

Endometrial Protection

  • Risk of unopposed estrogen à endometrial hyperplasia
  • Combination OCPs vs. Intermittent progestin therapy

Insulin sensitizers

 Metformin

  • A biguanide – the most widely used drug worldwide for the treatment of type 2 diabetes.
  • Primary action – inhibits hepatic glucose production
  • Secondarily increases peripheral sensitivity to insulin

Clinical Evidence for Polycystic ovary syndrome

  • 1996 study by Nestler demonstrated reduced circulating insulin levels and decreased ovarian secretion of androgens Studies demonstrating decreased clinical signs of androgen excess are limited
  • 2003 Meta-analysis showed PCOS women on Metformin 3.88 times more likely to ovulate
  • Indian Diabetes Prevention Programme and U.S. Diabetes Prevention Program have shown that metformin decreases the relative risk of progression to type 2 diabetes by 26% and 31% respectively
  • Limited evidence suggests that OCPs alone can aggravate insulin resistance and glucose intolerance.

Recommendations

  • Androgen Excess Society recommends that all women with PCOS be screened for glucose intolerance at the initial presentation and every 2 years thereafter.
  • AES does not mandate the use of metformin until more studies can demonstrate efficacy.
  • Metformin use should be considered in all patients with PCOS and glucose intolerance.
  • American Association of Clinical Endocrinologists recommends that metformin be considered the initial intervention in most women with PCOS, particularly those who are overweight or obese.

Adverse Effects

  • Lactic acidosis – rare complication (0.3 episodes per 10,000 patient-years).
  • GI distress – nausea and diarrhoea in 10-25% of patients
  • B12 Malabsorption.
  • Category B drug – no teratogenic effects in animal models and limited human anecdotal evidence

 

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