Polycystic ovarian syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS) manifested by Amenorrhoea (absence of menstruation), Hirsutism (excessive growth of Androgen dependent sexual hair in facial and central part of body) and Obesity associated with enlarged polycystic ovaries.

• This heterogeneous condition is characterised by excessive Androgen production by the ovaries mainly.

• PCOS is a multifactorial and polygenic condition.

◾Diagnosis is based upon the presence of any two of the following 3 criteria:

1. Oligo and/or Anovulation
2. Hyperandrogenism
3. Polycystiy ovaries

Incidences =

Incidences varies between 0.5 – 4%, more common amongst infertile women. Prevalent in young reproductive age group (20 – 30%).

Pathology :-

• Typically, the ovaries are enlarged.
• Ovarian volume >= 10 cubic cm.
• Stroma is increased.
• Capsule thickened and pearly white in colour.
• Presence of multiple follicular cysts measuring about 2-9 mm in diameter are crowded around cortex.

Histologically, there is thickening of tunica albuginea. The cysts are follicles at varying stages of maturation and atresia. There is theca cell hypertrophy.

Patient may present with features of diabetes mellitus.

Clinical features :-

• Increasing obesity (abdominal – 50%)
• Menstrual abnormalities (70%)
• Hirsutism
• Acne
• Acanthosis nigricans= specific skin changes due to insulin resistance
• HAIR-AN syndrome (Hyperandrogenism, Insulin Resistance, Acanthosis Nigricans)

Investigations :-

• Sonography= TVS – ovaries >10 cubic cm. Increased no. of peripherally arranged cysts.
• Serum levels=
  • LH level is elevated and/or the ratio LH: FSH > 2:1
  • Raised level of oestradiol and oestrone
  • SHBG (sex hormone binding globulin) level is reduced.
  • Hyperandrogenism
  • Raised serum testosterone> 150ng/dl
  • Raised fasting insulin level
• Laparoscopy= Bilateral polycystic ovaries

Pathophysiology :-

Exact pathophysiology is not clear. It may be discussed under following heads:

1. Hypothalamic – pituitary compartment abnormality
2. Androgen excess
3. Anovulation
4. Obesity and insulin resistance
5. Long term consequences

Possible late consequences of PCOS:-

• Obese women are at risk of developing diabetes mellitus
• Risk of developing Endometrial carcinoma
• Risk of hypertension and CVS diseases
• Obstructive sleep apnoea

Treatment Planning :-

Treatment is primarily targeted to correct the biochemical abnormalities:

• Hyperandrogenemia
• Hyperinsulinemia
• Hyperlipidemia
• High serum oestrogens
• Androgenic follicular microenvironment
• Hypersecretion of LH
• Low serum SHBG
• Low FSH
• Insulin resistance
• Low serum progesterone

Treatment :-

• Weight reduction in obese patient is first line of Treatment
• Ovulation induction is achieved by Clomiphene citrate
• Metformin improves metabolic syndrome by reducing all parameters (weight, BMI, hyperinsulinemia, Hyperandrogenism)
• Laparoscopic ovarian drilling (surgery) is done in cases found resistant to medical therapy. Earlier, wedge resection of ovaries was done.
• Ovarian diathermy is done in cases desiring pregnancy.
• Bariatric surgery may be indicated in some PCOS women who are morbidly obese.
• Hyperthroid state should be treated by throxin.
• Suppression of Hyperandrogenism can be achieved by using oral contraceptives, glucocorticoids, antiandrogen preparations.
• Life style modification can be great help in early stage.

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