Polycystic Ovarian Syndrome is a spectrum of disorders encompassed by the diagnosis of polycystic ovaries on ultrasound scan (USS) in lean women with regular menses (periods) and minimal signs pf hyperandrogenism (increased male hormone influence) in the form of acne and/or hirsutism (increased facial/chest hair) at the mild end, to obese, very hirsute women with infrequent or no period and severe disease.
It is by far the commonest cause of anovulatory infertility (infertility related to lack of ovulation) and hirsutism.
PCOS can occur at any age, but it seems to be most apparent in the age group 20 to 36 years.
Typically, the woman has normal growth and pubertal development, although hirsutism may develop before menarche (age of onset of periods). Periods may be regular from the onset or normal for a variable time. Usually before age 25, the woman will start to miss periods, with eventual prolonged duration of no ovulation and no periods.
Most patients present with infertility and hirsutism that is usually confined to the face (75%), no periods(50%), and obesity (40%). Others may have irregular periods (30%), painful periods (20%) and evidence of ovulation (20%).
Diagnosis is by clinical features in addition to the typical polycystic appearance of the ovaries on ultrasound scan with the lack of ovulation. Blood tests can also be done to check different hormones and confirm the diagnosis. Fasting insulin concentration and blood sugar can also be checked because of the associated risk of diabetes.
The increased insulin resistance and increased male hormone effect (hyperandrogenism) cause a decrease in the high density lipoprotein (the 'good' cholesterol) and an increase in triglycerides and the very low density lipoprotein (the 'bad' cholesterol) which can lead to an increase in the risk of cardiovascular disease.
Despite the infrequent periods, the oestrogen level in the blood is not decreased, and, therefore, there is no risk of osteoporosis. On the other hand, the prolonged exposure to unstopped oestrogen poses a risk of endometrial hyperplasia (overactivity of the cells of the lining of the uterus), which can lead to irregular uterine bleeding or uterine cancer.
Treatment is not always necessary if a woman is having a period every 6 to 8 weeks at the most. But if the time between periods is longer, then it is best to treat in order to oppose the effect of oestrogen and achieve regular periods of withdrawal bleeds. This is done by using the combined oral contraceptive pill -even when contraception is not an issue.
If a woman wishes to become pregnant, ovulation can often (75%) be induced with Clomid, with pregnancy occurring in about 35%. If this is unsuccessful, stronger medication can be used to stimulate the ovaries and induce ovulation. If all attempts with medication fails, then ovarian electrocautery ('drilling') should be considered, maybe before going on to assisted conception and in-vitro fertilisation (IVF).
If a woman is suffering from hirsutism, then antiandrogen treatment (medication to counteract the effect of the male hormone) - in addition to the contraceptive pill - can be used.
Advice regarding weight loss is very important in obese patients, as weight loss alone can, in some cases, be sufficient to improve some of the symptoms - especially the infrequent periods.
Finally, it is important to realise that PCOS is not a disease. It is a syndrome involving different systems in the body. We have to explain to the patients - to a certain extent - how the systems interact in order for them to be able to help themselves. --courtesy Gynecare
