Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a relatively common health problem, affecting about 3% to 10% of women around the world [1]. PCOS is characterized by an imbalance in reproductive hormones (elevated androgen levels) [2]. PCOS, most commonly, presents with irregular periods and is one of the main causes of infertility [3].

Symptoms:

1. Irregular menstrual cycle: At least 70% of women with PCOS experience oligomenorrhea (nine periods or lesser per year) or amenorrhea (three or four consecutive months with no period) [4].

2. Infertility due to prolonged anovulation (no ovulation) [4].

3. The appearance of cysts on one or both ovaries [3].

4. Excessive facial hair, also called hirsutism. Excessive acne on face, chest and upper back [4].

5. Weight gain or difficulty losing weight [5].

Both genetic and environmental factors contribute to development of PCOS. Hormonal disturbances combined with other factors, including obesity, ovarian dysfunction and hypothalamic pituitary abnormalities contribute to the aetiology of PCOS [4]. Two of the most well-known causes are listed below:

Hyperandrogenism: Elevated levels of luteinizing hormone (LH) and gonadotropin–releasing hormone (GnRH) result in stimulation of the ovarian thecal cells which, in turn, produces more androgen [2].

Insulin resistance: Insulin stimulates human thecal cells to synthesise testosterone by human thecal cells, which in turn leads to hyperandrogenism. Hyperinsulemia is another factor that influences PCOS [6]. Obesity worsens insulin resistance, thereby increasing hyperinsulinemia.

Diagnosis:

Patients with PCOS are sometimes asymptomatic or they may present with multiple gynaecologic, dermatologic, or sometimes metabolic manifestations. They most commonly come with complaints of oligomenorrhea (infrequent menstrual periods), amenorrhea (no menstrual periods), or infertility [7].

Diagnosis can be accomplished by a detailed history and physical examination and basic laboratory testing, mostly without the need for ultrasonography. The Endocrine Society advises clinicians to diagnose PCOS using the 2003 Rotterdam criteria [7].

Treatment:

There is no cure available to PCOS. Symptomatic treatment along with life-style changes is the best course of treatment. Long-term management of PCOS: The first line of treatment for PCOS is lifestyle changes, weight loss, diet and exercise. This increases insulin sensitivity. Oral contraceptives have been the go-to for treatment of PCOS. They provide relief through suppressing pituitary LH secretion, suppressing ovarian androgen secretion, increasing circulating SHBG levels. Risk factors with oral contraceptives need to be weighed before treatment plan is established. Some studies have progestin containing IUD’s to be of value in treatment. In morbidly obese women, bariatric surgery is recommended for patients with BMI higher than 40. Currently, studies are being conducted to prove efficacy of pharmacological treatment of obesity as a long-term benefit to managing PCOS [8].

Treatment of anovulatory infertility: One of the recently popular first-line of therapy for ovulation induction is letrozole (aromatase inhibitors). Traditionally, clomiphene citrate (CC) has been used to treat anovulatory women.  The proposed benefits of letrozole include a shorter half-life than clomiphene, more favourable effects on the endometrium, potentially higher implantation rates, and lower multiple pregnancy rates due to mono-follicular ovulation. Generally, clomiphene is started at 50 mg per day for 5 days and increased by 50 mg per day in following cycles, increased up to a maximum daily dose of 150 mg/d, if the patient doesn’t ovulate. Metformin, is often, times used as an adjuvant to clomiphene treatment.  Gonadotrophins are used for ovulation induction in women with no success using clomiphene. As second-line treatments, in-vitro fertilization (IVF) and ovarian surgery (laparoscopic ovary drilling) [8].

Hirsutism and acne treatment: Other than hair removal techniques (waxing, shaving, plucking, laser removal), some drugs maybe prescribed to control excessive hair growth. The most common are spironolactone, flutamide and other therapies including eflornithine. Hormonal contraceptives provide some relief from acne associated with PCOS and can be used along with standard topical acne therapy (e.g., retinoids, antibiotics, benzoyl peroxide) or can be used separately [7].

[1] W. M. Wolf, R. A. Wattick, O. N. Kinkade, and M. D. Olfert, “Geographical prevalence of polycystic ovary syndrome as determined by region and race/ethnicity,” International Journal of Environmental Research and Public Health, vol. 15, no. 11. MDPI AG, 20-Nov-2018, doi: 10.3390/ijerph15112589. [2] U. A. Ndefo, A. Eaton, and M. R. Green, “Polycystic ovary syndrome: A review of treatment options with a focus on pharmacological approaches,” P T, vol. 38, no. 6, pp. 336–355, Jun. 2013. [3] “About Polycystic Ovary Syndrome (PCOS) | NICHD – Eunice Kennedy Shriver National Institute of Child Health and Human Development.” https://www.nichd.nih.gov/health/topics/pcos/conditioninfo (accessed Apr. 03, 2020). [4] H. Teede, A. Deeks, and L. Moran, “Polycystic ovary syndrome: A complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan,” BMC Medicine, vol. 8. BioMed Central, p. 41, 30-Jun-2010, doi: 10.1186/1741-7015-8-41. [5] “Polycystic ovary syndrome | womenshealth.gov.” https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome (accessed Apr. 03, 2020). [6] J. E. Nestler, D. J. Jakubowicz, A. Falcon de Vargas, C. Brik, N. Quintero, and F. Medina, “Insulin Stimulates Testosterone Biosynthesis by Human Thecal Cells from Women with Polycystic Ovary Syndrome by Activating Its Own Receptor and Using Inositolglycan Mediators as the Signal Transduction System 1,” J. Clin. Endocrinol. Metab., vol. 83, no. 6, pp. 2001–2005, Jun. 1998, doi: 10.1210/jcem.83.6.4886. [7] T. Williams, R. Mortada, and S. Porter, “Diagnosis and treatment of polycystic ovary syndrome,” Am. Fam. Physician, vol. 94, no. 2, pp. 106–113, Jul. 2016, doi: 10.3803/jkes.2007.22.4.252.[8] R. S. Legro, Evaluation and Treatment of Polycystic Ovary Syndrome. MDText.com, Inc., 2000.