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All about PCOS

What is PCOS?

PCOS is a condition characterized by:

• Polycystic ovaries (multiple tiny ovarian cysts) easily recognized by ultrasound imaging.
• Lack of normal ovulation (anovulation).
• Hirsutism, acne oily skin complexion caused by elevated levels of male hormones (androgens).
• Obesity and insulin resistance (affecting about 50% of women with PCOS). High insulin level (insulin resistance) can trigger excess male hormone production by the ovaries, interfere with normal egg production and cause in infertility.

Medical Risks Associated With PCOS

Now that you have been diagnosed with polycystic ovary syndrome, you may ask "what does it mean?”
Several conditions are associated with this diagnosis:

• Infertility (ovulation disorder).
• Bleeding problems.
• Increased facial hair growth (hirsutism) and acne (due to increased male hormone levels).
• Increased risk of uterine and possibly breast cancer.
• Increased risk of obesity.
• Untreated women with PCOS, especially those with insulin resistance, have three times the risk of diabetes and seven times the risk of heart disease compared with women without PCOS. High insulin levels can stimulate cell growth and may accelerate the growth of cancer cells which have increased number of insulin receptors.
• High insulin also elevates "bad" cholesterols levels and increases the risk of blockage of arteries and cardiovascular disease.

How is PCOS Diagnosed?

• Many patients with this condition present with infrequent or no periods, obesity and increased facial hair or acne.
• Vaginal ultrasound (above, left) frequently demonstrates enlarged ovaries with multiple tiny cysts around the periphery of the ovary arranged in “pearl necklace” formation.
• Blood tests: FSH, LH, E2 on the third day of your menstrual cycle. Other frequently ordered hormone tests include prolactin, TSH, total and free testosterone, DHEAS, fasting blood sugar and insulin levels.
• On laparoscopy  (above, right) the PCOS ovary appears enlarged with pearly white smooth surface.

Am I Insulin Resistant?

Insulin resistance is increased in women who are overweight and non exercisers. While there is no real good test for insulin resistance, your doctor may order a fasting blood sugar and insulin levels, triglycerides, HDL cholesterol and measure your blood pressure. If two or more tests are abnormal, your doctor may suggest that you are insulin resistant.

How is PCOS treated?

In young women who do not wish to be, pregnant, treatment most often involves regulation of the menstrual cycle utilizing oral contraceptive therapy in combination with testosterone blocking agent such as Spironolactone (Aldactone). If facial hirsutism or acne is a problem, your physician may also recommend using an insulin sensitizing agent such as Metformin as a first-line therapy. Studies had shown that Metformin treatment can decrease male hormone levels, reduce weight and resume spontaneous ovulation. In addition, anti insulin medications may also lower the risk for heart disease and cancer by lowering blood insulin level.

Which treatment is right for me if I plan to conceive?

Several treatment options are there for you to consider:

• Weight loss: interestingly, studies have demonstrated that even only a 5-10% weight-loss can result in lower male hormone levels and resumption of normal ovulation.
• Laparoscopic ovarian drilling:  has been advocated as an alternative to medical treatment for PCOS. During the laparoscopy, about 10 tiny holes are drilled into each ovary. The end result is that male hormone production from the ovary is decreased, restoring ovulation and resulting in up to 50% pregnancy rate. The treatment is not widely used because it carries a risk of scar tissue formation and tubal infertility.
• Ovulation inducing medications:

Clomiphene Citrate – Clomiphene Citrate  tablets are given by mouth (Clomid, Serophene, and Letrozole); they work by stimulating the pituitary gland to release follicle stimulating hormone (FSH), which regulates the development of your eggs. Most often, 50-100 milligrams tablets taken are daily for five days. Development of the eggs can be monitored by ultrasound or detected by over-the-counter ovulation predictor tests. Most patients who respond to this treatment will do so with lower dosage although some patients require a daily dose to 150 mg for five days.

Gonadotropins – Patients who do not respond to this therapy are referred to as Clomiphene-resistant. Such patients often require injectable hormones (gonadotropins) to induce ovulation.

Metformin – PCOS patients may benefit from the addition of insulin sensitizing agent (Metformin) to either Clomid or injectable hormone therapy.

I do not want to conceive - I have facial hair - what are my options?

• Testosterone blocking medications - Facial hair may be caused by elevated male hormones. Effective therapy is, therefore, directed towards blocking the male hormone from reaching the hair follicle or by reducing the amount of active male hormone in the blood stream; one commonly used androgen-receptor antagonist is Spironolactone (Aldactone) given at a daily dose of 100-200 milligrams. Another medication used to treat excessive hair growth is Finasteride given at a dose of 5 mg daily.
• Oral contraceptives - are often given together with testosterone blocking medications because they provide contraception and suppress ovarian male hormone production. Several months of medical therapy are needed before significant improvement in the symptoms is noted.
• Weight loss and hair removal - Medical therapy is best utilized in conjunction with weight loss and mechanical therapy such as electrolysis and laser for permanent hair removal.

Polycystic Ovarian Syndrome - PCOS

Polycystic Ovarian Syndrome-PCOS is characterized by enlarged ovaries with multiple small cysts, an abnormally high number of follicles at various states of maturation, and a thick, scarred capsule surrounding each ovary.
Polycystic ovarian syndrome (PCOS), is a primary ovarian condition and is characterized by the presence of many minute cysts in the ovaries and excess production of androgens. Polycystic ovarian syndrome can be found in apparently normal women and the full expression of the disease so-called 'Stein-leventhal syndrome' is very uncommon. Polycystic ovarian syndrome is frequently associated with weight gain, excessive hair growth in the face and body, irregular and infrequent periods or absent periods, infrequent or absent ovulation, miscarriage and infertility. The cause of PCOS is not fully understood. There are long-term risks of developing type 2 diabetes, cardiovascular disease and cancer of the womb. Women diagnosed as having PCOS before pregnancy have an increased risk of developing gestational diabetes.

Symptoms

• Normal / irregular periods [Oligomenorrhea]
• Normal Weight / Weight gain, acne
• Insulin resistance and diabetes
• Infertility
• Hirsutism and Virilization due to increased level of androgens (excess hair on the body like male, husky voice, baldness and clitoral enlargement)
• Reversal of FSH / LH ratio
• Increased ovarian volume with thick pearly white capsule

Diagnosis of PCOS

The diagnosis of PCOS is made primarily on the woman's presenting history and examination. The diagnosis can be confirmed on ultrasound or by measuring the woman's hormonal levels. If the ultrasound and the blood tests are normal it does not mean that the woman does not have the condition. However, it has also been found that women who do not have problems with their periods or of excessive hair growth can have ovaries which on ultrasound have the appearance of being polycystic.

• Diagnosing PCOS can be difficult since a specific test cannot be performed nor is there a set list of symptoms that doctors can look for. Each woman’s experience of PCOS is unique. Diagnosis is made when woman has irregular or absent period. Generally diagnosis is done in based on
• Complete physical and pelvic exam
• Any physical sign of abnormal hair growth
• Acne , male pattern baldness.
• Transvaginal ultrasound for thickness of endometrium and cystic ovaries.
• Lab test include the test for LH/FSH, Testosterone /DHEA, thyroid function, prolactin, GTT, and cholesterol.

Since PCOD is quite common in India, we have extensive experience in preventing OHSS, and have not needed to hospitalise a patient for this complication for the last 10 years. This is because we use a special technique during egg collection with a double lumen needle, which allows us to remove all the granulosa cells from each follicle at the time of egg retrieval, by flushing each follicle meticulously. Since these cells are the ones responsible for producing the chemicals which cause OHSS, by removing them we reduce the risk of our patients getting OHSS dramatically.