Polycystic Ovarian Syndrome
(PCOS)
PCOS is a common condition affecting
up to 10% of all women and the incidence is higher
in infertile women.
Often symptoms present at the time of first menstruation
(menarche), but some patients develop symptoms later
in their reproductive lives and the clinical presentation
varies from subtle to overt.
It is now well established that PCOS runs in families, although different individuals may have different forms of the syndrome.
PCOS usually presents in two forms:
A. Classical PCOS (Stein Leventhal
Syndrome) with:
- Obesity
- Hirsutism (excess hair growth), alopecia (male pattern baldness), with elevated male hormone levels (i.e. testosterone)
- Irregular or absent menstruation since puberty
- Lack of ovulation
and infertility
- Ovaries with many small cysts, hence the term polycystic
- Insulin resistance with a greater risk of developing diabetes
Non-Classical PCOS, or PCOS variants:
This subtle condition is far more prevalent than the classical form of PCOS and patients present with some of the features (1-6 above), but not all. Specifically, these patients may be thin but still manifest the aspects of classical PCOS.
Women with PCOS appear to be at risk of developing other health problems during their lives including:
- Insulin resistance and diabetes
- Lipid abnormalities (cholesterol and triglycerides)
- Sleep apnea
- Endometrial cancer
PCOS Physiology
Patients with PCOS have a disruption
to several hormonal systems leading to abnormal
ovulation, hirsutism, and possibly insulin resistance.
The associated obesity may further compound these
hormonal aberrations so that a vicious cycle is present
with the hormonal problems causing obesity, often
refractive to standard weight loss regimens, and the
obesity aggravating the hormone problems.
The following hormonal problems are associated with PCOS.
- Pituitary -There is an excess production of LH compared to FSH (greater than 3: 1) leading to disruption of the menstrual cycle and increased androgen (male hormone) production in the ovary.
- Ovary-Increased production of estrogen without progesterone may lead to the development of a thickened uterine lining (endometrial hyperplasia) and possibly uterine cancer over many years. Testosterone production is also increased in the small cysts of the ovary and this may be converted to more estrogen in the fat cells.
- Adrenal-An elevation in adrenal androgens (DHEAS) is seen in some PCOS patients.
- Insulin Resistance- This phenomenon relates to an insensitivity of the PCOS patient to insulin requiring the body to produce a greater amount of this hormone to process a given amount of carbohydrate. Since insulin has the effect of increasing testosterone production in the ovary, a self-perpetuating cycle is produced.
PCOS- Diagnosis
There are several aspects important to the diagnosis of PCOS:
- History and physical examination (this will enable classical PCOS patients to be differentiated from the non classical)
-
Hormonal testing including fasting glucose and
insulin levels
- Ultrasound
to visualize the ovaries
-
Endometrial biopsy to exclude pre cancerous
uterine conditions
Treatment of PCOS
Treatment of PCOS can take many forms including:
- Weight loss (this may be difficult
because of high testosterone levels) but may be
aided by the administration of insulin
lowering medications as well as following a
low carbohydrate diet and an appropriate exercise
regimen.
- Regulation of menses may be accomplished with regular administration of progesterone or the use of an appropriate oral contraceptive (one low in androgens).
- Ovulation induction with:
- Insulin resistance may be treated
with weight loss and metformin
(Glucophage), Actos (pioglitazone), or Avania
(rosiglitazone). These medications are insulin-sensitizing
agents that improve glucose tolerance, insulin resistance,
and lower testosterone levels. Hence, improving
the hormonal environment and often establishing
normal ovulation.
- Hirsutism- May be treated with an appropriate oral contraceptive preparation, Spironolactone, and cosmetic approaches such as electrolysis and laser.
- Surgery- In refractory cases,
laparoscopic surgery
with a YAG laser may be used to reduce the ovarian
production of testosterone by removing some of the
tissue that is producing the testosterone.
In all cases of PCOS it is important that endometrial cancer, or pre cancer, be excluded by sampling of the endometrium either in the office with endometrial aspiration or curettage.
Conclusions
PCOS remains a challenging condition
that is widespread. Dr.
Kustin won a prize for his scientific research
on PCOS and is very familiar with the subtleties of
diagnosis and treatment. The cornerstone of care is
proper evaluation and individualized treatment, which
is monitored appropriately.
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