Polycystic Ovarian Syndrome (PCOS)

• PCOS is heterogenous disorder of uncertain cause. Some evidence shows it is a genetic disease (autosomal dominant) with high genetic penetrance but variable expressivity in females. It is a health problem that affects 1 in 10 women. It is the most common endocrine disorder which is caused by an imbalance of reproductive hormones which creates problems in ovary. In PCOS, the egg from the ovaries may not develop as it should or it may not be released during ovulation. This causes missed or irregular menstrual periods. Irregular periods can lead to : (a) Infertility (b) development of cysts (small fluid-filled sacs) in the ovaries.
• PCOS encompasses hyperandrogenism which has internal effects on ovarian function and metabolism and external manifestation on skin. Ovarian dysfunction is associated with erratic menses and anovulation.
•  Cysts are a symptom instead of the cause. Cysts are the immature follicles whose development has arrested at early antral stage. Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgenic hormones, mainly testosterone.
• Women with PCOS experience an increased frequency of hypothalamic GnRH pulses, which in turn results in an increase in LH/FSH ratio. Hyperinsulinemia amplifies hyperandrogenism . Majority of women are obese and insulin-resistant. Hyperinsulinemia increases GnRH pulses frequencies. LH over FSH dominance increased ovarian androgen production, decreased follicular maturation.  Adipose tissue possesses aromatase which convert androstenedione to estrone and testosterone. Hence, obese women will have high androgen production.

CAUSES: 

(a) Excess insulin = when cells become resistant to the action of insulin, blood sugar as well as insulin levels arises. This leads to increase in androgen production.

(b) Low grade inflammation = this stimulates polycystic ovaries to produce androgen in PCOS women.

(c) Other causes are hypothyroidism, Cushing syndrome and hyperprolactinemia.

MECHANISM:

(a) Androgen control the development of male traits. Women with PCOS have more androgens than normal. High levels prevent the ovaries from releasing an egg (ovulation) and cause extra hair growth and acne (signs of PCOS).

(b) The action of insulin on the liver leads to decrease production of sex hormone binding globulin which results in increased free testosterone.

SIGNS AND SYMPTOMS:

1. Chronic anovulation 
2. Reduced menstrual bleeding
3. Absence of menstrual bleeding (Amenorrhea)
4. Hirsutism (increased facial and body hair)
5. Alopecia (baldness)
6. Obesity (high waist to hip ratio)
7. Infertility or recurrent miscarriages.
8. Anxiety\
9. Oily skin, severe and late-onset acne
10. pelvic pain
11. patches of thickened, dark, velvety skin- a condition called as Acanthosis nigricans 

DIAGNOSIS:

1. Physical examination : BP, BMI, WHR, extra hair on body, acne, skin discoloration, enlarged thyroid gland.
2. Pelvic exam: if ovaries are enlarged or swollen.
3. Ultrasound: cysts in ovaries or check the endometrium lining of uterus
4. Blood tests: androgen level, cholesterol level etc.
5. Anti-Mullerian hormone (AMH) is increased in PCOS, and become a best diagnostic criteria.

TREATMENT:

1. Medical:  Metformin is used to treat type II diabetes. It improves insulin levels and bring back the normal cycle. Clomiphene is ovulation inducer and improves fertility. Oral contraceptives decrease the action of insulin and hence increase the production of sex hormone binding globulin which leads to low levels of free testosterone.
2. Taking estrogen and progestin daily regulate ovulation, relieve symptoms and protect against cancer.
3. Lifestyle changes: exercise, eating healthy and avoid junk.