PCOS is a disorder of chronic ovulatory dysfunction or anovulation ( absence of ovulation) and hyperandrogenism( abnormally elevated male hormones )and ultrasound showing multiple tiny cysts in the ovary.
Effects of PCOSPCOS is not just a disease confined to the ovaries. The clinical manifestations range from obesity, fertility issues to increased risk of diabetes and even endometrial cancer.
- Obesity –Tendency for central obesity adding to risk of
- Hirsuitism which is increased facial and body hair
- Hyper pigmentation of skin around flexures, nape of the
neck due to increased insulin hormone.
Absence of Ovulation- leading to absent periods, scanty periods or irregular periods with heavy bleeding
Subfertility– difficulty in conceiving due to anovulation
Long term problems
- Risk of Type II diabetes and insulin resistance even when controlled for BMI
- Hypertension – High blood pressure
- Disorders in lipid metabolism leading to hyperlipidemia
- Risk of heart disease and stroke
- Endometrial hyperplasia and endometrial cancer ( cancer of uterine lining ) due to accumulation of uterine lining due to prolonged stimulation of uterine cells to hormone estrogen and lack of progesterone hormone.
Risks in Pregnancy
- Increased risk of miscarriage
- Gestational diabetes
What causes PCOS
- Strong evidence of a genetic disease showing clustering of cases in families and monozygote twins
- Heterogenous disorder of uncertain etiology
- However, clinical severity of PCOS appears largely determined by factors such as obesity
- Lifestyle modification
- Weight reduction by even 5 – 10% in obese PCOS can result in ovulation in 1 in 2 cases without medication
- Diet modification( avoid rice, potatoes, pasta, white sugar, junk food and processed food. Include more of whole grain ,bread, dark green leafy vegetables, fruits with peel where possible.
Four main issues in the management of PCOS are
- Regulation of menses
- Control of hirsuitism
- Management of Insulin Resistance (IR) syndrome and its associated risk of Type II DM, cardio vascular disorders
Regulation of Periods
It is very important to regularize the periods because irregular periods can increase the rate of endometrial cancer threefold. In general, atleast 4 menses per year is required to control this risk.
- Oral contraceptive pills (OCP )is used as first line mainstay of treatment.
- Progesterone – for those who might prefer not to cycle every month, periodic progesterone withdrawal is an option. A 7 – 10 day course of Progesterone every 2 – 3 months may result in 4 – 6 menses per year.
- Metformin – Improving IR and treating the root cause can restore menstruation.
- Metformin can also induce normal, ovulatory cycles in 40 – 90% of patients. A 6 month trial period is reasonable. Can be taken long term if found effective.
Treatment of Hirsuitism
- Weight loss, Metformin, OC Pills and certain other drugs that reduce testosterone action reduces hirsuitism
- A trial of 6 – 12 months is needed and most patients need a combined medical and mechanical method of management like ,waxing, cream, laser, electrolysis etc.
- PCOS accounts for 75% of anovulation with risk of miscarriage in 30 – 50%
- Clomifene Citrate (CC) is the drug of choice for inducing ovulation
- In severe PCOS with resistance to tablets – injections may be used
- Surgery may be suggested as a last resort if resistant to tablets and injections. Surgical intervention is by keyhole laparoscopic ovarian drilling,
- This is done as a daycare procedure.
Long term Management
Increased physical activity and dietary modifications are the cornerstones to successful weight loss and cardio vascular risk reduction.
Long term goals are directed at early diagnosis of Type II DM, Dyslipedemia by doing GTT
( Glucose Tolerance Test ) and Lipid Profile every year.