KOCHI: Polycystic Ovarian Syndrome (PCOS) is one of the most common endocrine dysfunctions found in women of reproductive ages with a prevalence of approximately 5-10% worldwide.
PCOS among adolescents is an emerging problem that needs careful assessment, timely intervention and appropriate treatment. It is a chronic condition having physiological and reproductive manifestations which usually begin in adolescence, then progress to include infertility and increasing metabolic complications over time.
A timely diagnosis of PCOS leads to awareness of this condition associated with hormonal and metabolic complications and provides an opportunity for healthy lifestyle counselling, testing for co-morbidity or medications.
PCOS is a multifactorial disease. It has a strong hereditary basis and polygenic genetic factors. The other hereditary factors include early age of sexual maturation, premature fetal development, and family history of PCOS. Low birth weight and fetal exposure to androgens may contribute to the development of PCOS. Environmental factors include physical inactivity and consumption of fast food containing high amounts of saturated fats and steroids leading to obesity, and its associated insulin resistance which increases hormonal imbalance such as increased androgen levels, adding to the risk for development of PCOS.
Pathophysiology of PCOS
The pathophysiology of PCOS involves complex interactions between the actions of gonadotropins, androgens and insulin. An important element of this syndrome is the insulin resistance in the body leading to increase in insulin levels or hyperinsulinemia. Insulin stimulates the ovarian production of androgens and impedes ovulation, either by directly affecting follicular development or by indirectly increasing intra ovarian androgen levels (hyperandrogenism) or altering gonadotropin secretion.
Androgens interfere with hypothalamic function by increasing Gonadotropin releasing hormone (GnRH) pulse frequency that favors increased leutinizing hormone (LH) secretion, which stimulates the ovaries to produce more androgens. Decrease in follicle stimulating hormone (FSH) secretion leads to less conversion of androgens to estradiol and impaired follicular development, resulting in menstrual irregularities that are characteristic of PCOS.
Clinical features
The clinical features of PCOS can be classified as reproductive, metabolic and psychosocial features. The reproductive features include menstrual dysfunction, hirsuitism, baldness, acne infertility, miscarriage, gestational diabetes and endometrial hyperplasia. The metabolic features are insulin resistance, metabolic syndrome, dyslipidemia, impaired glucose tolerance, diabetes mellitus and hypertension.
Anxiety, depression, poor self esteem and poor quality of life are the psychosocial features of PCOS. Women with PCOS often seek care for menstrual disturbances, clinical manifestations of androgen excess and infertility. About 50% of women have no other signs or symptoms. Up to 1 in 3 premenopausal women have polycystic ovaries on ultrasonogram and 1 in 3 of those women have PCOS.
The diagnosis of PCOS requires presence of two or more of the following: menstrual irregularities, anovulation, androgen level in blood or clinical features of hyperandrogenism and polycystic ovaries.
The investigation of the condition can be conducted through hormone profiling – LH, FSH and Testosterone, Pelvic Ultrasonogram (usually at least 12 follicles, small in size in an enlarged ovary) and investigations for other complications.
PCOS can be managed through lifestyle modification – weight reduction and exercise, treatment for acne and hirsuitism, screening and treating insulin resistance and other lifestyle diseases, ovulation induction, laparoscopic surgery and assisted conception
There is a need to increase awareness among children about lifestyle modifications to prevent obesity and PCOS, so as to avoid metabolic and fertility problems in the future. Early screening and detection of the syndrome based on clinical findings offers an opportunity for early intervention to prevent further complications. A family physician will surely be able to help in the initial stages.
The author is a specialist in Family Medicine at VPS Lakeshore.
(Views expressed by the author are her own)