Polycystic Ovary Syndrome (PCOS) is a hormonal disorder frequently seen in the women of reproductive age. With the global prevalence ranging between 2.2 and 26%, it is estimated that 10 million women worldwide are affected by this disorder, and 50% of them are still undiagnosed! It takes a 2-3 year period for the correct diagnosis to be made after the patient seeks health care for various symptoms of this disorder. Various Indian studies have put the prevalence between 9.13 and 22.5% in India. According to a study by the All India Institute of Medical Sciences (AIIMS), 20-25% of Indian women have PCOS, 60% of them are Obese, 70% have Insulin Resistance and 60-70% has high Androgen (male hormone) levels. More than 50% of the affected women go on to develop Diabetes Type 2 before they reach 40 years of age. PCOS is the most common cause of treatable infertility, which accounts for over 70% of anovulatory infertility (infertility due to absence of ovulation) .
Described way back in 1935 by Drs. Irving Stein & Michael Leventhal, the disorder is still not fully understood and we do not have a cure! There is an enormous lack of general public awareness in addition to delayed and misdiagnosis by the health care providers. Varying prevalence, wide range of symptom-spectrum, different diagnostic criteria, juggling treatments, myths and misconceptions about the disorder add fuel to the fire. PCOS is a major public health problem that affects women’s physical and mental health besides being a significant contributor to the overall burden of type 2 diabetes in women in pre-diabetic Indian subcontinent.
Symptoms
The symptoms of PCOS may start as early as puberty or even before that. Cosmetic concerns include acne, unwanted male-pattern hair growth on body (hirsutism), scalp hair loss and male-type baldness. These cosmetic issues along with obesity lead to a low self esteem. Gynecological symptoms include infrequent, irregular or prolonged menstrual cycles. For example, you might have fewer than nine periods a year, more than 35 days between periods and abnormally heavy periods. Many features of PCOS, including acne, menstrual irregularities are common in normal puberty. Menstrual irregularities with anovulatory cycles (cycles with no ovulation) and varied cycle length are common due to the immaturity of the hypothalamic-pituitary-ovarian (hormonal) axis in the 2- to 3-year time period following the first menstrual period (menarche). Persistent infrequent periods 2 to 3 years beyond menarche predict ongoing menstrual irregularities and greater likelihood of underlying ovarian or adrenal dysfunction.
In women with PCOS, there is a tendency to gain weight easily and this weight is centered on the belly (central/truncal obesity), leading to a negative body image over time. Women with PCOS have a hard time shedding weight despite sincere efforts. PCOS leads to difficulty getting pregnant, and this is due to absence of ovulation and hormonal disturbances. Later in life, these women go on to develop serious long-term health consequences like uterine cancer, Type 2 Diabetes, high blood pressure, high cholesterol and a cluster of these problems raising their risk of heart diseases enormously.
Causes
The exact cause of PCOS is not known. Insulin resistance and high Androgen levels are present in majority of these women. Insulin is the hormone produced in the pancreas that converts foods into energy. With Insulin resistance, the body cells respond inefficiently and inadequately to the normal levels of Insulin. This triggers excessive Insulin release from the pancreas, leading to Hyperinsulinemia. Hyperinsulinemia, in turns, leads to excessive androgen production from the ovary, disturbing the hormonal milieu and causing anovulation. Hyperinsulinemia also acts as an appetite stimulant, and makes weight loss difficult.
Genes also have a role to play in the development of PCOS. You are at a higher risk for this disorder if your sister or mother has PCOS.
Treatment
Since there is no cure for PCOS, treatments are targeted to tackle insulin resistance and high androgen levels. Correct diagnosis of PCOS impacts on the likelihood of associated health risks and leads to appropriate intervention, depending upon the woman’s age, reproductive status, and her own concerns. The first line treatment for almost all symptoms of PCOS is lifestyle modifications in the form of healthy eating and regular exercise, and maintaining an ideal body weight. Irregular periods may be tackled by combined oral contraceptives aimed at regularizing periods. Acne and hirsutism may be treated with various anti-androgen medications. For fertility, you may need medications which help with ovulation. Insulin sensitizers like Metformin and Inositols may be prescribed in case of Insulin resistance. As an Infertility Specialist, I come across many patients with PCOS and infertility in my OPDs at Mumbai and Srinagar, and majority of them benefit with simple measures like weight loss and exercise. There are some who need fertility drugs, insulin sensitizers and assisted reproduction in the form of In Vitro fertilization (IVF). To start with, excessive weight is the first thing I like to correct before embarking on complex fertility treatments. It is important to emphasize to our patients the immense importance of healthy life style changes and weight loss, which also goes a long way to tackle other health hazards resulting due to PCOS. Long term health consequences of PCOS like Type 2 Diabetes, high blood pressure, high Cholesterol, Metabolic Syndrome, and Uterine Cancer lead to significant morbidity and mortality in addition to an immense economic burden. The total cost of testing and providing care to reproductive-aged PCOS women in the United States was dollar 4.36 billion in the year 2005. The health budget of India is grossly inadequate to cover the consequences of PCOS. Because the cost of the diagnostic tests accounts for a relatively minor part of the total costs (approximately 2%), more widespread and liberal screening for the disorder and its consequences appears be a cost-effective strategy, leading to earlier diagnosis and intervention and possibly the amelioration and prevention of serious sequelae. Studies suggest that PCOS research is underfunded, considering its pandemic prevalence, economic burden, metabolic morbidity and negative impact on quality of life. According to the US National Institutes of Health Office of Disease Prevention, greater education of all health care providers, general practitioners, specialists and the general public by professional societies, the scientific community, and patient advocates regarding this disorder is needed to nip the evil in its bud.
Dr Sabahat Rasool is Fertility Consultant & Reproductive Medicine Specialist, Gynaecworld Fertility Centre, Mumbai. She has also worked as Asst. Prof. Grant Medical College, Mumbai