Poly Cystic Ovarian Syndrome (PCOS)/ Poly Cystic Ovarian Disease (PCOD)

Poly Cystic Ovarian Syndrome (PCOS)/ Poly Cystic Ovarian Disease (PCOD)

Poly Cystic Ovarian Syndrome (PCOS) seemed to be a rare condition in earlier days but it has been rampant coming to 2020 A.D. It has affected nearly 6–10% of women childbearing ages globally and has the prevalence of about 5–10% in Nepalese women. It is one of the most common endocrine and metabolic disorders in premenopausal women. PCOS is a disorder which affects how a women ovary works. It involves infrequent, irregular or prolonged menstrual periods, and often excess male hormone (androgen) levels. The ovaries develop numerous small collections of fluid called follicles and may fail to regularly release eggs.

Poly Cystic Ovarian Disease (PCOD) is a condition in which the ovaries contain many immature or partially mature eggs, which can not be discharged. They, eventually, turn into cysts. This results in the enlarged presentation of the ovary. In PCOD, the hormonal imbalance leads to the collection of mature eggs in the ovaries, as they cannot be discharged. These also become cysts and some of the cysts lead to more cysts and this cycle continues. PCOD seems to be more common than PCOS. Despite the differences, PCOD and PCOS are used as interchangeable terms now and then.

The ovaries produce higher levels of androgen (male sex hormone)than normal, and this interferes with egg development and release. Some of the eggs develop into cysts, which are little sacs filled with liquid. Instead of releasing during ovulation, these cysts build up in the ovaries and may even get enlarged. This might stop the release of the egg leading to anovulation.

For the conformation of PCOS, any two characteristics of the following should be present:

• Oligo/Anovulation
• Sign of Hyperandrogenism (excess male sex hormone): deepening voice, clitoromegaly, acne, abnormal or excessive hair growth
• Polycystic ovaries (either 12 or more follicles on one ovary measuring 2–9 mm in diameter &/or increase of total ovarian volume to more than 10 ccs)

However, simply the presentation of the multiple cysts in the ovaries is known as PCOD. It appears because of hormonal disturbances and may or may not be associated with other metabolic disorders in the body. It may be present as a dormant form of PCOS. The risk factors, symptoms and consequences of PCOD and PCOS overlap, nevertheless, the women with PCOD may conceive successfully compared to those with PCOS.

Risk factors

Hormonal imbalances and genetics play a crucial role in causing both PCOS and PCOD.

1. Hormonal imbalances: Disturbances in the level of luteinizing hormone (LH), free testosterone, androgen, prolactin and sex hormone-binding globulin (SHBG) is observed. Raised level of the preceding four hormones is seen and a low level of SHBG is observed in PCOS. The exact reason for hormonal changes is not known. However, it has been suggested that the problem may start in the ovary itself, in other glands that produce these hormones, or in the part of the brain that controls their production. The changes may also be caused by the resistance to insulin.
2. Genetics: PCOS is believed to run in the family. In case of occurrence of the condition in any first-degree relation (e.g. mother, sister or aunt)or among twins, risk of developing PCOD/PCOS is increased. Even though, this suggests there may be a genetic link to PCOS, specific genes associated with the condition have not yet been identified.
3. Insulin resistance: Insulin is a hormone produced by the pancreas which helps to control the amount of sugar in the blood. It helps to move glucose from the blood into cells, where it’s broken down to produce energy. Insulin resistance means the body’s tissues are resistant to the effects of insulin. When the cells become resistant to the action of insulin, the blood glucose level may rise and the body might produce more insulin to compensate it. The increased amount of insulin and LH both combined might increase androgen production, causing disturbances in the normal ovulation. Insulin resistance can also lead to weight gain, which can make PCOS symptoms worse, as having excess fat causes the body to produce even more insulin.
4. Stress: Besides the daily stresses of life, our body is kept into additional stresses in the form of excessive exercises and workouts, consumption of unhealthy diet. The constant stresses may cause irregularities in the hormonal systems of the body resulting in PCOS.
5. Smoking: Smoking in women is found to increase the androgen level and decrease the estrogen level thus causing imbalances in the hormones and worsening the symptoms of PCOS. It has the potential to increase both metabolic syndrome and hyperandrogenism in women with PCOS.
6. Modern lifestyle: It is generally all about more crash diets, less exercise or physical activity, less time to spend on taking care of their own health. The continuous exposure of all these factors ultimately might result in the hormonal imbalances and thus PCOS/PCOD.

Symptoms

Not all women with PCOS/PCOD will have all of the symptoms, and each symptom can vary from mild to severe. Some women only experience menstrual problems or are unable to conceive, or both. The symptoms associated with PCOS/PCOD are listed below:

1. Thinning of hair or Hairloss
2. Hirsutism (excess hair growth in the areas where it doesn’t grow in female normally like hair growth in the face, chin, neck, chest, back, abdomen, etc.)
3. Irregular periods or absence of periods (because of hormonal irregularities)
4. Difficulty getting pregnant/Infertility (because of irregular ovulation or failure to ovulate)
5. Weight gain (might occur because of insulin resistance in the body)
6. Fatigue (might be because the body is unable to get enough energy to work through glucose because of insulin resistance)
7. Acne(because of the excess amount of male sex hormones in the body)

Consequences

1. Fertility problem: PCOS appears to be a common cause of infertility in women. As women with PCOS fail to ovulate or ovulate infrequently (irregular or absent periods), conceiving might be difficult. Also, hormonal impairment in women with PCOS makes conception a challenging task.
2. Depression and anxiety: Symptoms of PCOS may affect your self-esteem and confidence and increase stress leading to increased release of the stress hormone, Cortisol. Cortisol interferes with the brain chemicals modulating the moods and this imbalance of the brain chemicals may lead to depression and anxiety.
3. Metabolic disorders: Women with PCOS might develop high blood pressure, high triglycerides and LDL level, low HDL level, increased blood sugar, etc.
4. Cardiovascular diseases: Risk of cardiovascular disease increases with increased blood sugar, blood pressure and cholesterol levels.
5. Non-alcoholic fatty liver disease (NAFLD): It may appear as a complication of metabolic syndrome.
6. Type 2 Diabetes Mellitus occurs because of insulin resistance in the body. It can be managed with the use of insulin sensitizers like Metformin which helps to normalize the blood sugar levels.
7. Obstructive sleep apnoea: The exact pathophysiology of this in PCOS women is yet not clearly understood. However, it is believed to be associated with the key characteristics of PCOS i.e., increased androgen level, insulin resistance, obesity. Difficulty in breathing during sleep may be frequently seen in overweight women.
8. Endometrial cancer and endometrial hyperplasia: The continuous thickening of the endometrium in absence of menstrual cycle causes the endometrium to be very thick (endometrium hyperplasia). Women with irregular or absent periods (less than 8 periods per year) for many years might have a greater risk for endometrial cancer. The risk can be minimized by restoring the regular menstrual cycle by using contraceptive pills or intrauterine system.
9. Obesity: The insulin resistance in women with PCOS is the reason for obesity. Usually, fat deposition in the abdominal areas is observed.

Investigations

• A pelvic exam
• Blood test for hormone levels and to screen for diabetes and high cholesterol
• Ultrasonography (USG) of ovaries
• Laparoscopy
• Hysteroscopy

If diagnosed with PCOD/PCOS, additional tests for complications:

• Periodic checks of blood pressure, glucose tolerance, and cholesterol and triglyceride levels
• Screening for depression and anxiety
• Screening for obstructive sleep apnoea

Treatment

Treatment may be either or a combination of both the non-pharmacological and pharmacological approaches.

1. Non-pharmacological: The first line intervention is lifestyle modification including weight management with calorie restriction, diet modifications and regular exercises. Low carbohydrate or low glycemic diet can provide additional benefits. Exercise helps to lower blood glucose level. If you have PCOS, increasing your daily activity and participating in a regular exercise program may help to manage or even prevent insulin resistance and help to keep your weight under control with a lower risk of developing diabetes. Possible exercises may include yoga, cardio, cycling, skipping, jogging.

2. Pharmacological: The symptoms of PCOS can be managed by the use of various medications. Doctors might recommend the following medications to regulate your menstrual cycle:

1. Combined birth control pills: pills containing estrogen and progestin help in decreasing the androgen production and regulating estrogen. The regulation of the hormones tends to decrease the risk of endometrial cancer and also manage excess hair growth, abnormal bleeding and acne.
2. Progestin therapy

Medications like Clomiphene (anti-estrogen medication), Letrozole (helps in stimulating the ovary), Metformin (oral hypoglycemic agent- aids in improving the insulin resistance) might be recommended by your doctor to regulate ovulation.

A surgical procedure named laparoscopic ovarian drilling (LOD) may be recommended in case the fertility medicines are not effective. In LOD, the tissues in the ovary which are producing androgens (testosterone) are destroyed using heat or laser.

Birth control pills, Spironolactone, Eflornithine may be prescribed to manage symptoms like acne and hirsutism.

The chances of pregnancy in women with PCOS increases with the appropriate treatment.

References

1. NHS. Poly Cystic ovary syndrome (PCOS). https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/. Accessed 21 July 2020.
2. Mayo clinic. Poly Cystic ovary syndrome (PCOS). https://www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439#:~:text=Polycystic%20ovary%20syndrome%20(PCOS)%20is,fail%20to%20regularly%20release%20eggs. Accessed 21 July 2020.
3. PCOS awareness association. PCOS or PCOD? Most people don’t even know. https://www.pcosaa.org/tealtalkblog/2020/2/24/pcos-or-pcod-most-people-dont-even-know. Accessed 21 July 2020.