NEWSLETTER
POLYCYSTIC OVARY SYNDROME: An Endocrine problem of Females
Dr. Uzma Imran - Consultant Obstetrician & Gynaecologist Aga Khan Women’s Hospital, Karimabad
Polycystic ovarian syndrome (PCO) is a common disorder defined by the presence of two of the following three criteria
- Oligo- and/or anovulation
- Hyperandrogenism
- Polycystic ovaries (either 12 or more peripheral follicles 2-9mm in diameter or increased ovarian volume (greater than 10 cm)
Combined with exclusion of other etiologies such as congenital adrenal hyperplasia (CAH), androgen secreting tumors, Cushings syndrome, hyperprolactinaemia and thyroid dysfunction.
There is considerable heterogeneity of symptoms and signs among women with PCOS & for an individual these may change over time.
CLINICAL PRESENTATION OF PCO’S
The clinical presentation is quite varied leading from Hyperandrogenism (acne, hirsutism, alopecia-without virilization), Menstrual disturbances, Infertility, Obesity to even asymptomatic (only with polycystic ovaries on ultrasound).
The Endocrinological evidence is very important in determination of this disorder.
- Increased Serum Fasting Insulin (which is not routinely measured; insulin resistance or impaired glucose tolerance assessed by GTT)
- Increased Androgens (Testosterone & androstendione)
- Serum LH/FSH levels: according to latest RCOG guidelines on PCOS; a raised LH/FSH ratio is no longer a diagnostic criterion for PCOS owing to its inconsistency.
- Increased Sex Hormone Binding Globulin (SHBG) results in elevated Free Androgen Index.
- Increased Oestradiol, Oestrone (neither measured routinely as very wide range of values)
- Increased Prolactin levels
According to latest RCOG guidelines diagnosis of PCOS can only be made when other etiologies have been excluded. The recommended baseline screening tests are:
- Thyroid function tests
- Serum Prolactin levels
- Free androgen index (total testosterone divided by sex hormone binding globulin x 100 to give a calculated free testosterone level)
In cases of clinical evidence of hyperandrogenism and total testosterone greater than 5 nmol/l, 17- hydroxyprogestrone should be sampled and androgen secreting tumors should be ruled out. If there is a clinical suspicion of Cushing syndrome, this should appropriately be investigated.
Long term health consequences of PCOS include Type 2 Diabetes Mellitus (especially if women with PCOs are obese (BMI > 30), strong family history of Type 2 Diabetes Mellitus, should be offered GTT), Dyslipidemias, Hypertension, cardiovascular diseases, Endometrial carcinoma and obstructive sleep apnoea. In case of pregnancy, there is higher incidence of gestational diabetes mellitus and other complications as compared to controls.
MANAGEMENT OF PCOs
Management of PCO is symptom-oriented. Patients should be counseled for the possible long-term risks to health and should be advised for lifestyle modification.
Obesity
Obesity worsens both symptomatology and endocrine profile especially if BMI > 30 kg/m2. It is sensible to keep carbohydrate content down and avoid fatty foods. If required, refer to dietician. Regular exercise (aiming for a mean 30 minute sweat-inducing exercise daily) is recommended.
Anti-obesity drugs such as Sibutramine, Orlistat, Rimonabant and insulin sensitizing agents such as Metformin and Thiozolidinedions (such as proglitazone and roziglitazone) can also be tried. Bariatric surgery may also have a role in grossly obese patients.
Menstrual Irregularity
Oligo or amenorrhea in women with PCOs may predispose to endometrial hyperplasia and later carcinoma. It is good practice to recommend treatment with progestogens to induce a withdrawal bleed at least every 3-4 months. Regular induction of a withdrawal bleed with cylical gestogens, such as progestogens for at least 12 days, oral contraceptive pills or the Mirena intrauterine system would be advisable in oligomenorrhoeic women with PCOs. Women who are ogliomenorrhoeic and do not have normal withdrawal bleeds should be investigated and managed according to local protocols. This may include ultrasound scan, endometrial sampling and/or hysteroscopy.
Hyperandrogenism and Hirsutism
Drug therapies may take 6-9 months or longer before any improvement or hirsutism is perceived. Physical treatments may include electrolysis, waxing and bleaching which may be helpful.
Hyperandrogenism is usually managed with Dianette containing ethinyl estardiol in combination with cyproterone acetate. A new OCP namely Yasmin may also benefit. Alternatives include spironolactone, flutamide and finasteride (are not routinely prescribed because of potential adverse effects, reliable contraception is required)
Infertility
Ovulation induction may be difficult, and require progression through various treatments which should be monitored carefully to prevent multiple pregnancies. As mentioned before, weight loss should be foremost and first line for treatment for obese women.
Ovulation can be induced with antiestrogens clomifene citrate (50-100mg) taken from days 2-6 of cycle induces ovulation in 80% of women while pregnancy occurs in only 40%. The therapeutic options for patients who are resistant to antiestrogens are either parenteral gonadotrophins or laparoscopic ovarian drilling. If gonadotrophins are used, dose monitoring is required to reduce the risk of multiple pregnancy and ovarian hyper-stimulation syndrome. Ovarian diathermy is free of above risks and does not require intensive ultrasound monitoring, although both above mentioned options achieve similar pregnancy rates at 12 months.