Polycystic Ovary Syndrome: A Ravana With Many Heads

PCOS is in fact a multifactorial and multi-system disorder that manifest in various ways.

A condition first recognised nearly 80 years ago affects as many as 10-20 percent of reproductive age group women. That means in regions where the prevalence is about 20 percent, like in Kashmir valley, 1 in 5 women have this condition. The condition is called polycystic ovary syndrome, commonly referred to as PCOS. The name of this condition is a misnomer as multiple cysts in ovaries, as the name suggests, is not the only feature or the predominant feature of this disorder. PCOS is in fact a multifactorial and multi-system disorder that manifest in various ways. Some girls with PCOS have menstrual problems, some have cosmetic problems (like excessive facial hair, oily skin or acne) whereas others have cysts in ovaries or difficulty in conceiving. A girl with PCOS may have one, two or many of these features at the same time.

Symptoms of PCOS can start in adolescence but may be noticed any time in a woman’s reproductive life. These symptoms of PCOS vary widely. For convenience, we can group these features into five sets:

1. Menstrual Disturbances And Infertility: The body’s network of hormones is a finely tuned system. When any hormone in a system is out of balance, a body-wide havoc ensues. For reproductive system, two pituitary hormones (LH and FSH) regulate the production of two female hormones (estrogen and progesterone). These four hormones work hand in hand and regulate ovulation (that is, monthly release of an egg from an ovary) and menstruation. In PCOS, the balance of LH and FSH is somehow disturbed. This, in turn, disturbs the balance of estrogen and progesterone. Thus, imbalances of these hormones manifest as menstrual dis-turbances. A woman with PCOS may have irregular cycles, delayed cycles or heavy cycles. As menstrual disturbances indicate underlying problematic ovulation, this makes PCOS a leading cause of infertility (difficulty in conceiving). In addition, if a woman fails to menstruate regularly, the uterine lining becomes overstimulated by estrogen, which is a risk factor for endometrial cancer.

2. Distressing Cosmetic Problems: Girls with PCOS do not only have problems with female hormones, they also have elevated levels of androgens (male hormones like testosterone) in their blood. Many girls with PCOS may have normal levels of androgens in blood but they have enhanced sensitivity to androgens. This hormonal abnormality manifest as oily skin and severe acne over face and other parts of the body, growth of excessive, coarse, thick and dark hair over face, chest, upper back, around the navel and other regions of the body. Elevated androgen levels also give rise to thinning of or even loss of scalp hair, especially over temples (male-pattern baldness). These are the most anxiety-causing symptoms of PCOS in young girls.

3. Multiple Cysts In Ovaries: The name of PCOS is because of this manifestation of the disorder. But it should be noted that polycystic ovaries (that is, presence of multiple cysts in ovaries) is only one of the features of this hormonal disorder. Multiple cysts in ovary is not necessary for diagnosis of PCOS. Furthermore, a girl can have multiple cysts in ovaries because of many other conditions. Ultrasonography of pelvic organs can detect these multiple cysts. Many girls with PCOS are distressed when told that they have multiple cysts in ovaries. Remember, this is just one of the features of PCOS. Several girls undergo serial ultrasonography of ovaries from time to time to see the number or size of these cysts. This is unnecessary as these cysts may come and go. They have less correlation with the hormonal condition of the body. The presence of ovarian cysts or size of ovaries may be important for diagnosis of PCOS, but not for management of PCOS. 

4. Predisposition To Other Chronic Diseases: PCOS is not only the problem of disturbances of reproductive hormones and androgens. Many women with PCOS also have excessive amounts of insulin in body, yes you read it right, the same insulin that you read in relation to diabetes. This is because these women have resistance of their cells to this hormone. The primary task of insulin is to maintain a normal blood glucose level by moving this glucose into cells that use it for energy. But excess insulin also promotes fat storage, and people with high levels of insulin often gain weight on a normal diet and have a great difficulty in losing weight. Half or more of women with PCOS become obese. When insulin resistance is left untreated for a long time, the continual pressure on the beta cells of pancreas to overproduce insulin can lead to Type 2 diabetes. This problem of insulin resistance also give rise to high triglyceride (TG) and low HDL (good cholesterol) levels in blood. Insulin resistance is also one of the factors that lead to high blood pressure (hypertension). Thus, a chain reaction is set in. Insulin resistance giving rise to obesity, diabetes, abnormal cholesterols levels and high blood pressure. These conditions together known as metabolic syndrome, in turn predisposes the individual to cardiovascular diseases (that is, heart attack and stroke).

5. Reduced Quality Of Life: This is often an ignored area of PCOS. Mental and emotional health is just as important as physical health. Approximately 34% of women with PCOS have depression compared to 7% of women in the general population and around 45% have anxiety, compared to only 18% of the general population. These women have a huge mental distress because of menstrual disturbances, distressing cosmetic symptoms especially excessive hair growth and weight issues. Whether anxiety or depression is secondary to distressing symptoms of PCOS or a primary condition per se is debatable. Girls with PCOS should remember that this is a manageable condition. There is no need to worry. These symptoms can be minimised to a large extent with proper life-style and medications.  

PCOS tends to run in families, with predisposing genes passed from either parent to both daughters and sons. In affected males, early balding or excessive hairiness can be a sign that the genes have been inherited. In women, symptoms can vary from being very mild to extensive. So when a women is diagnosed with this condition, it makes sense to look for features of PCOS in her family members. 


Diagnosing PCOS

Because of the varied features of PCOS and because its symptoms may also mimic some other serious disorders, several investigations may be needed to  obtain a correct diagnosis. The work-up is best done by an expert familiar with hormonal disturbances. Total or free testosterone, thyroid stimulating hormone (TSH), Prolactin and 17-OH progesterone levels are measured in the blood. Plasma lipids and blood glucose levels are estimated. Sometimes, LH, FSH, DHEAS and other investigations are ordered, depending upon the treating clinician.


Treating PCOS

Treatment of PCOS is problem-oriented. But a healthy life-style programme is for all patients with PCOS. The symptoms of many women are controlled by change in life-style only. For instance, weight loss itself improves insulin resistance, and thereby corrects hormonal imbalances. Many women with PCOS improves their menstrual cyclicity and infertility by reducing their body weight. To reduce insulin resistance further, a famous anti-diabetes medicine, called metformin is sometimes prescribed by clinicians. If irregular cycles is the main problem, then oral contraceptive pills is the mainstay of treatment. For excessive hair growth and acne, combination of oral contraceptive pills and spironolactone works best. Cosmetic measures are also used for acne and facial hair along with medicines. Infertility is helped by weight loss, ovulation induction by clomiphene or by using various assisted reproductive techniques. Remember, the earlier PCOS is recognised and treated, lower are the risks of developing complications later in life.

Dr M Shafi Kuchay is a Kashmiri Endocrinologist, working as consultant at Medanta, The Medicity Hospital, Gurugram, India.