OVERVIEW

The joy of every woman is to have a child of her own. A cute adorable child they can pamper and take care of with affectionate and tender loving care.
However, a disorder with the ovaries of a woman can hinder this blissful moment in their lives. A significant disorder of the ovaries which is the most common cause of infertility in women is Polycystic Ovarian Syndrome (PCOS).

What then is PCOS?

DEFINITION

Polycystic ovarian syndrome is a clinical syndrome characterized by mild obesity, irregular or no menstrual periods, and signs of excess male sex hormones called androgens.

These signs of androgen excess are acne and male secondary features such as deep voice, breast size reduction, and excess body hair. This syndrome is characterized by fluid filled sacs (cysts) present in the ovaries hence its name.
However, its diagnosis goes beyond the presence of cysts in the ovaries but the presence of the above clinical syndrome.

ETIOLOGY

Currently, the cause of PCOS remains unclear. However, current evidence suggests that the enzyme controlling the production of male hormones malfunctions. In view of this, the production of androgens increases.

The increase of male hormones increases the risk of metabolic syndrome (increased blood pressure, increased cholesterol levels and resistance to insulin effects). The hormone adiponectin produced by fat cells (adipocytes) amplifies the resistance to insulin in PCOS. This increases the risk of diabetes, heart, and blood vessel disorders.

The imbalance of hormones affects estrogen and progesterone levels which are responsible for the thickening of the endometrium (lining of the uterus) during menstruation. This causes endometrial hyperplasia which increases the risk of endometrial cancer (cancer of the uterus).

EPIDEMIOLOGY

PCOS is prevalent in the United States and is one of the most common endocrine disorders of reproductive-age women.

However, the signs of the clinical syndrome of PCOS differs in ethnic background. Women from South and East Asia have less body hair presentation as compared to women in Europe and United States.

Recent studies found an increase in incidence of acne, menstrual irregularities and skin disorders such as acanthosis nigricans, in women in South and East Asia.

In Africa, a recent study in Nigeria presented with 62 women having PCOS out of 342 women with infertility in infertility clinics at Enugu, South East Nigeria. From the study, the common presenting features among women with PCOS is infertility, oligomenorrhoea, obesity, hyperprolactinemia and hirsutism.

PATHOPHYSIOLOGY

The mechanism in PCOS involves anovulation which occurs due to increase in the stimulatory effect of the luteinizing hormone (LH) secreted by the anterior pituitary gland. This stimulates the ovarian theca cells which in turn increase the production of androgens.

Due to the decreased levels of follicle stimulating hormone (FSH) relative to LH, ovarian granulosa cells cannot convert the excess androgens to estrogens, which leads to decreased estrogen levels and eventually anovulation (no production of eggs).

SIGNS AND SYMPTOMS

Symptoms of polycystic ovarian syndrome normally develop during puberty and worsen with time. However, it defers from woman to woman.

The following are some of the signs in PCOS:

1. Hair growth in unwanted areas:

Normally known as ‘hirsutism’ in the medical field. It involves hair growing in places such as your face or chin, breasts, stomach, thumbs and toes.

2. Hair loss:

There is thinning of hair on the head. This could worsen in middle aged women.

3. Weight problems:

There is difficulty in losing weight and most women struggle with increased weight gain.

4. Acne or oily skin:

Because of the hormonal changes, there is development of pimples and oily skin. Take note that these skin conditions can occur without PCOS.

5. Sleep problems and fatigue:

This is known as sleep apnea. This sleep disorder, is characterized by inadequate body rest after having adequate sleep.

6. Headaches:

This is due to the hormonal changes.

7. Difficulty in getting pregnant:

A leading cause of infertility in women.

8. Menstrual problems:

This involves irregular periods. These include absence of menstrual periods for several months or presence of heavy bleeding during a period.

DIAGNOSIS

Your health practitioner can diagnose you of PCOS through the following procedures:

1. A detailed history of the signs and symptoms present, family, social, and sexual history: Emphasis would focus on the duration of the signs and symptoms, presence of infertility and obesity in the family, and concerns of losing weight and getting pregnant.

2. A thorough physical examination: During the physical examination, emphasis would focus on a pelvic examination. Here, the physician would inspect and feel areas of your body including the vagina, cervix, uterus, oviducts, ovaries and rectum. This is to identify any abnormalities.
The physician would also check your blood pressure, body mass index (BMI) and waist size. Your skin would also be checked for extra hair growth, acne and discolored skin which is key in PCOS.

3. Imaging studies such as pelvic ultrasound: This produces an image of your ovaries. The physician places the ultrasound device over your vagina to check for cysts in your ovaries.
The lining of the uterus is also checked. The uterus can be abnormally thickened. The ovaries may also be abnormally enlarged.

4. Laboratory tests: The physician can also take a blood sample for the following tests:
– Follicle-stimulating hormone levels
– Luteinizing hormone levels
– Testosterone levels
– Estrogen levels
– Human chorionic gonadotropin (hCG)
– Anti-Mullerian hormone (AMH)

TREATMENT

In treating PCOS, the following are considered in the choice of treatment:

1. Type and severity of symptoms
2. The age of the woman
3. Plans regarding pregnancy

General measures involved in treating PCOS are exercise, dietary changes and weight loss.

Exercising (at least 30 minutes a day) and reducing carbohydrates intake (foods such as bread, pasta, potatoes and sweets) can help reduce insulin levels when high. In most women, reduced insulin levels from weight loss ensure adequate ovulation.

Weight loss also reduces hair growth and risk of uterine lining thickening.

Medications used include the following:
1. Metformin – To reduce insulin levels
2. Clomiphene – To increase chances of conception
3. Spironolactone, cyproterone and oral contraceptives – To reduce unwanted hair growth
4. Benzoyl peroxide and tretinoin cream – To treat acne.

KEYPOINTS

1. PCOS is a common cause of ovulatory dysfunction.
2. Polycystic ovary syndrome is the most common cause of infertility in the United States.
3. PCOS is characterized with obesity, unwanted hair growth and irregular menstrual periods.
4. It derives its name from the presence of fluid filled sacs in the ovaries.
5. This syndrome varies from woman to woman.