What is polycystic ovary?

Polycystic ovary (PCO) also called as Stein-Leventhal syndrome is a vast spectrum of disease affecting a women’s health ranging from menstrual irregularities, acne, excess facial & body hair (hirsuitism), weight gain and problems regarding fertility along with cysts in the ovaries.

How common is PCO?

It is found in 10-20% of women of childbearing age. Almost 75% of women with irregular menses and/or infertility may have polycystic ovaries, as determined with both radiological and biochemical criteria. Polycystic ovaries have been found with sonography in more than 50% of women with regular menstrual cycles as well; however, most of the women had some degree of hirsuitism, acne, or male-pattern baldness.

What is the cause for PCO?

The exact cause for PCO is not known, although patients with PCO invariably have a mother, sister or aunt with a similar problem. It is also more common in girls born of consanguineous parentage. The exact genetic relationship is not known.

What exactly happens in PCOS?

To know this, we need to understand the normal ovarian anatomy. The ovaries are two small organs situated on either side of the uterus. The normal ovarian volume (length 3-5 cm, 1.5-3 cm in width, and 0.5-1.5 cm in thickness X 0.523) is around 10ml. Ovaries have follicles, which are cysts filled with liquid that hold the eggs. Each month about 20 eggs start to mature, but usually only one becomes dominant. As one egg grows, the follicle accumulates fluid in it. When that egg matures, the follicle breaks open to release the egg so it can travel through the fallopian tube for fertilization. When the single egg leaves the follicle, ovulation takes place.

In women with PCO, the ovary doesn’t make all of the hormones it needs for any of the eggs to fully mature. They may start to grow and accumulate fluid, but no follicle becomes fully mature. Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, menstrual cycle is irregular or absent. Also, the cysts produce male hormones, which continue to prevent ovulation.

The other issue that needs attention is that many women with PCOS are overweight, hence there seems to be a relationship between PCOS and insulin, which these people seem to be producing in excess. The ovaries also seem to be producing excess amounts of circulating androgens.

Which age group is more commonly affected?

Women in their 20-30 seem to be more commonly affected, although it can affect any women of childbearing age group.

What are the common symptoms of PCOS?

These can be grouped into three different categories:

1. Menstrual irregularities – This is the most common feature where patients come in with irregular cycles/ scanty periods (70%).
2. Features of androgen excess – 60% of women have hirsuitism, 25% also suffer from acne/ male pattern baldness.
3. Obesity & insulin resistance – 35% have features of obesity & insulin resistance. Clinical features of Insulin resistance is mainly limited to the black skin mark in the neck called Acanthosis Nigricans.
4. Infertility due to anovulation is found in 30% of women.

The condition sometimes refers as HAIRAN syndrome (HyperAndrogenism, Insulin Resistance, Acanthosis Nigricans)

What are the categories of PCOS?

1. Traditional PCOS — anovulatory, increased androgens, no insulin resistance
2. Endocrine syndrome X — anovulatory, increased androgens, insulin resistance or type 2 diabetes
3. Non-traditional PCOS — anovulatory, normal androgens, obese, insulin resistant or type 2 diabetes
4. Non-traditional PCOS — ovulatory, increased androgens, mild insulin resistance
5. Idiopathic hirsutism — ovulatory, increased androgens, no insulin resistance

What are the necessary investigations?

1. Laboratory investigations
   1. Blood sample for
      1. Serum Testosterone concentration (May be normal or raised, levels do not reflect the degree of hirsuitism)
      2. FSH/ LH ratio reversal
      3. SHBG – decreased owing to high insulin state with a consequent increase in circulating androgens
2. Pelvic ultrasound for
   1. Ovarian volume (> 10cc)
   2. Presence of follicular cysts (>8 cysts <10mm)
   3. Endometrial hyperplasia (>10mm)
3. Other investigations
   1. 17(OH)P to rule out LOCAH when serum testosterone levels are very high
   2. Short synacthen test to see for an exaggerated response to 17(OH)P in cases where required
   3. MRI to see for androgen producing tumors in cases where serum testosterone levels are very high
   4. Blood glucose levels as upto 40% of women can have impaired glucose tolerance and 10% have frank Diabetes mellitus
   5. Serum lipids

What are the treatment options available?

1. Weight loss
   This will reduce insulin resistance and thus hyperandrogenism. With loss of 5% body weight, they show a 40% improvement in hirsuitism.
2. Insulin sensitizers
   METFORMIN – Though this drug is mainly used in the treatment of Type 2 Diabetes Mellitus, it does not reduce the blood sugar in people with normal blood sugar levels. It improves insulin sensitivity with a corresponding reduction in circulating androgens, decreases LH levels and increases Sex hormone binding globulin levels, thereby regulating menstruation improving ovulatory function and thereby inducing fertility. No long-term studies are available to see the effect of metformin on hirsuitism.

   It is usually started in 500mg/day and gradually increased to a maximum of 1.5 gm/day. A word of caution about the gastrointestinal side effects of metformin.

3. HIRSUITISM
   Drug treatment for hirsuitism should be combined with local measures. Drug treatment can alter only new hair growth and does not have an effect on established hair. It takes 4-6 months for improvement to be visible and can recur once medications are stopped. Adequate contraception is mandatory as the drugs used can be teratogenic.

   Drugs available

   1. Oral contraceptive pills (OCP) – Regularises menstrual cycles and has best results on hirsuitism when combined with antiandrogens. The OCP containing cyproterone actetate (2mg) is preferred. These are available in packs of 21/ 28 (Containing active ingredient for 21 days and placebo for the remaining 7 days). They are to be taken cyclically. Menstrual cycles will regularize with medication. Washout period of 3-4 months required before conception.
   2. Spiranolactone – Has weak anti-androgen properties. Dose of 50 – 200mg/day can be used. Can cause intermenstrual bleeding. This can be avoided when used with OCP.
   3. Flutamide – Potent anti-androgen. Dose of 125mg/day.
   4. Finasteride- As effective as cyproterone. Adequate contraception is mandatory and a compulsory washout period of 3 months after drug cessation is necessary before conception.
4. Infertility
   Weight reduction is a must as obesity adversely affects fertility outcome. Ovulation induction regimens are indicated with drugs like Clomiphene citrate or Gonadotrophin preparations. Laproscopic ovarian diathermy is also used for restoring ovulation.

   Studies have shown that Metformin should be continued till 12 weeks after conception in women with PCOS as it helps in continuing the pregnancy.

What is the prognosis for PCOS?

Cysts are benign and they do not cause much problem even if they stay back. Probably women with PCO are at increased for developing Type 2 Diabetes mellitus and Dyslipidemia in future.