Polycystic ovarian syndrome (PCOS);

A woman having delayed periods with excessive hair growth on face and body must think of PCOD. So, if the monthly reminder (menses) is missed often, then rule out PCOD first in the early days itself (better before marriage). Women have two ovaries located in the pelvis alongside the uterus. The main functions of the ovaries are to release eggs and produce hormones. They are responsible for moods, sex drive and health. After getting a signal from the pituitary gland through the FSH (follicle stimulating hormone), the ovaries secrete oestrogen to attain menarche – the first monthly reminder of the presence of the ovary in an active reproductive phase.

It also aids in breast development, widening of the pelvis, flat pads in hips and pubic hair. In this fertile 30-35 years of monthly reminders, ovulation occurs on the 14th day of the menstrual cycle. As age advances, the quality of egg declines and the oestrogen level, which is very helpful in preventing fat deposits in arteries, gets cut off, which in turn makes women susceptible to coronary heart diseases.

At birth, the ovaries are provided with approximately one million eggs, each surrounded by cells which develop into a small fluid-filled blister known as a follicle. Each month, in women with regular periods (normal ovulation), one of these follicles will develop and grow to about 20 mm in diameter and then release a mature egg (ovulation), which passes into the fallopian tubes. If there is fertilisation, the fertilised egg (embryo) continues its course through the tube into the uterus where it will implant in the lining (endometrium) and develop as a pregnancy. If there is no fertilisation, the endometrium is shed as a menstrual period after 14 days of ovulation.

Three important groups of hormones - oestrogens, androgens and progesterone - are also produced in the ovary. These, in turn, are regulated by the release of two additional hormones - follicle stimulating hormone (FSH) and luteinizing hormone (LH) - from the pituitary gland which is located at the base of the brain. These two ‘reproductive’ hormones influence the development of the follicle and the timing of ovulation.

For many couples, infertility can become the central issue of their lives. Infertility is generally a complex problem and may involve one or both partners who are trying to conceive. PCOD is most common female infertility cause which should be treated before marriage itself if menstrual irregularity is noticed.

PCOD – poly cystic ovarian disease - is the most common ovarian dysfunction and endocrine disorder which affects approximately 15-20 per cent of women in the reproductive age. The affected women often have signs and symptoms of elevated androgen levels, menstrual irregularity and weight gain, abnormal hair growth on the face or the body and no periods at all (amenorrhea). The syndrome has an initial onset in the peripubertal years and is progressive.

PCOD is a female hormonal imbalance where maturing eggs fail to be expelled from the ovary, creating an ovary filled with immature follicles. The cysts then contribute to the hormonal imbalance, which causes more cysts and enlarged ovaries. Polycystic ovary disease is characterized by anovulation (no formation of egg) irrespective of periods (regular or irregular or absent) and hyperandrogenism (elevated serum testosterone and androgen). Also women with PCOD who conceive have a higher rate of early foetal loss than women without PCOD.

PCOD women have fewer chances to conceive, compared to normal women who ovulate every month. Normal women get 12 chances in a year to conceive. But PCOD women hardly get 3-4 chances due to delayed periods.

Relative causes of PCOD

PCOD does run in families. Several genes contribute to the pathogenesis of PCOD. Many of these genes are related to insulin resistance with elevated fasting blood insulin levels. The high levels of androgenic hormones interfere with the pituitary ovarian axis, leading to increased LH levels, anovulation, amenorrhea and infertility.

Young diabetic women treated with insulin are at special risk of PCOD. The amount of insulin injected by insulin-dependent or insulin-requiring diabetics is far in excess of what the body produces naturally.

Obesity is a common part of PCOD and many of these women are also insulin-resistant. When a woman is insulin-resistant, her fat cell does not respond normally to the insulin in the blood stream. Weight gain in itself can result from high serum insulin levels.

Symptoms of PCOD

The most common symptoms of PCOD are

Irregular and infrequent menstrual periods or no menstrual periods at all;

Infrequent or no ovulation with increased serum levels of male hormones - testosterone;

Inability to get pregnant within one year of unprotected sexual intercourse;

Weight gain or obesity;

Diabetes, over-production of insulin with abnormal lipid levels and high blood pressure;

Excess growth of hair on the face, chest, stomach in male pattern (hirsutism) and male-pattern baldness or thinning of hair;
Acne, oily skin or dandruff;

Patches of thickened and dark brown or black skin on the neck, groin, underarms, or skin folds;

Skin tags, or tiny excess flaps of skin in the armpits or neck area;

Male fat storage patterns - abdominal storage rather than standard female pattern on thighs, hips and waist; and Mid-cycle pain indicating painful ovulation - due to the enlargement and blockage of the surface of the ovaries;

Consequences of PCOD

Hyperinsulinemia in PCOD has also been associated with high blood pressure and increased clot formation and appears to be a major risk factor for the development of heart disease, stroke and type-II diabetes

Women with irregular cycles need to have other conditions ruled out, such as anorexia, stress or exercise-induced problems with the menstrual cycle, other hormonal problems such as thyroid disease or medication problems.

The general consequences of PCOD are:
Menstrual irregularities - Constant oestrogen production stimulates growth of the uterine lining which usually induces very heavy uterine bleeding. The bleeding episodes may occur after long gaps of time (oligomenorrhea) or, for some women, not at all (amenorrhea). Irregular periods are a nuisance and suggest some hormonal disorder or risk of endometrial thickening.

Impaired Fertility- Another consequence of incomplete follicular development is a lack of regular ovulation. Irregular ovulation usually means that pregnancy is more difficult to achieve. Similarly, if ovulation is not taking place, it is not possible to conceive.

Miscarriage - While miscarriage seems an unfortunate chance event for most couples, it is clear that women with PCOD may be at increased risk of early foetal loss. The hormonal environment in PCOD may interfere with egg development within the follicle and disrupt embryo implantation within the uterus.

Hair and skin problem Androgen (male hormone) is a byproduct of the ovaries. In PCOD, the production of androgen, such as testosterone, is excessive, which causes abnormally increased hair growth and contributes to acne formation. The assessment of excessive hair growth (or hirsutism) may be difficult.

Obesity - About 50 per cent of women with PCOD are obese. Obesity tends to enhance abnormal estrogen and androgen production in this disorder, which only magnifies the problems of irregular bleeding and excessive hair growth.

More important, the long-term effects of unopposed oestrogen place women with the syndrome at considerable risk for endometrial cancer or breast cancer.

Diagnosis of PCOD - The signs of PCOD are ovaries slightly enlarged and may contain 10 or more small cysts located at the periphery of the ovary, which have led to polycystic ovaries. The size of these cysts is generally less than 8 mm and can usually be detected by ultrasound examination. Pelvic and physical examination, ultra sound scanning, blood tests to measure hormone, insulin and cholesterol levels will also help. Height and weight will be noted along with any increase in facial or body hair or loss of scalp hair, acne and discoloration of the skin under the arms, breasts and in the groin. Elevated androgen levels or testosterone confirms the diagnosis.

General treatment for PCOD

Mostly patients take treatment for cosmetic ailments like obesity, unwanted hair growth or acne. They will not mind the underlying delayed and heavy periods which is to be treated first. Medical treatment should be given to correct irregular menstruation, eradicate excessive hair growth or achieve pregnancy.

Because there is no cure for PCOD in Allopathy, it concentrates on ways of management to prevent further problems. The treatment can be as:

Medication: To induce a menstrual period and restore normal cycles, birth control pills are used. It regulates menstruation, reduces androgen levels and helps to clear acne. The method of treatment depends on the severity of the symptoms and whether the patient is trying to get pregnant or not. If not trying to conceive, then they are treated with hormones, including the birth control pill. If trying to become pregnant, fertility drugs and other treatments are necessary.

Getting normal can be tried:

1) Eating a balanced diet low in carbohydrates and maintaining a healthy weight can help lessen the symptoms of PCOD.
2) Regular exercise helps weight loss and also helps the body in reducing blood glucose levels. Aerobic activities such as walking, jogging or swimming are advised. With reduction of weight and reduction in insulin resistance, regular periods will mostly resume. It is not always possible to promise a woman who has achieved ideal body weight and who continues with exercise that she may have regular ovulation.
3) For reducing excess body and facial hair, bleaching, removal by waxing or a hair removal cream can be used. For permanent facial hair removal, electrolysis is done.

Treatment of PCOD for the infertile patient will usually focus on ovulation inducting. They induce ovulation with fertility drugs. Sometimes fertility drugs may induce risk of multiple pregnancies.

Surgery: Doctors used to perform ovarian surgery called wedge re-section to help patients with PCOD to ovulate. A recent treatment option uses laparoscopy to treat patients with PCOD. During operative laparoscopy, a laser is used to drill multiple holes through the thickened ovarian capsule. When wedge re-section or drilling is used, there is risk of inducing adhesions around the ovary. As a result of these, surgeries are used as the last resort.

Polycystic ovary disease Definition Polycystic ovary disease is a condition in which there are many small cysts in the ovaries, which can affect a woman's ability to get pregnant.

Alternative Names Polycystic ovaries; Polycystic ovarian syndrome (PCOS); Stein-Leventhal syndrome; Polyfollicular ovarian disease. Causes Polycystic ovary disease affects hormone cycles. Hormones help regulate the normal development of eggs in the ovaries. It is not completely understood why or how hormone cycles are interrupted, although there are several ideas.

Follicles are sacs within the ovaries that contain eggs. In polycystic ovary disease, there are many poorly developed follicles in the ovaries. The eggs in these follicles do not mature and, therefore, cannot be released from the ovaries. Instead, they form cysts in the ovary.

This can contribute to infertility. The immature follicles and the inability to release an egg (ovulate) are likely caused by low levels of follicle stimulating hormone (FSH), and higher than normal levels of male hormones (androgens) produced in the ovary.

Women are usually diagnosed when in their 20s or 30s. Women with this disorder often have a mother or sister who has symptoms similar to polycystic ovary disease.

Symptoms If you have polycystic ovary disease, you are likely to have some of the following symptoms:

Abnormal, irregular, or very light or infrequent menstrual periods
Absent periods, usually (but not always) after having one or more normal menstrual periods during pubertysecondary amenorrhea)
Acne that gets worse
Decreased breast size
Development of male sex characteristics (virilization), such as increased body hair, facial hair, a deepening of the voice, male-pattern baldness, and enlargement of the clitoris
Increased hair growth; body hair may be in a male pattern
Poor response to the hormone, insulin (insulin resistance), leading to a build-up of insulin in the blood
Weight gain, or obesity
Exams and Tests During a pelvic examination, the health care provider may note an enlarged clitoris (very rare finding) and enlarged ovaries.

Tests include:

Abdominal ultrasound
Abdominal MRI
Biopsy of the ovary
Estrogen levels
Fasting glucose and insulin levels
FSH levels
LH levels
Male hormone (testosterone) levels
Urine 17-ketosteroids
Vaginal ultrasound
Blood tests that may be done include:

Pregnancy test (serum HCG)
Prolactin levels
Thyroid function tests
Treatment Medications used to treat the symptoms of polycystic ovary disease include:

Birth control pills
Clomiphene citrate
Treatment with clomiphene citrate causes the pituitary gland to produce more FSH. This causes the egg to mature and be released. Sometimes women need stronger fertility drugs to get pregnant.

In women with polycystic ovary disease who also have insulin resistance, glucophage (Metformin), a medication that makes cells more sensitive to insulin, has been shown to make ovulation normal.

Losing weight (which can be difficult) may help to reduce the high insulin levels in the blood. For women with this condition who are overweight, weight loss can reduce insulin resistance, stimulate ovulation, and improve fertility rates.

Outlook (Prognosis) Women who have this condition can get pregnant with the right surgical or medical treatments. Pregnancies are usually normal.

Possible Complications Increased risk of endometrial cancer
Obesity-related conditions, such as high blood pressure and diabetes
Possible increased risk of breast cancer
When to Contact a Medical Professional Call for an appointment with your health care provider if you have symptoms of this disorder.

References Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby;2007.