PCOS

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic disorders among women of reproductive age.  It’s called PCOS because of the presence of multiple cysts that line the peripheral ovarian tissue.

Women suffering from PCOS present with a constellation of symptoms. In younger women, reproductive symptoms predominate while presence of metabolic features increases with age.

Apart from cysts on the ovaries, there may be irregular menses, excess androgen levels, sleep apnea, high stress levels, High blood pressure, skin tags, infertility, acne, oily skin, and dandruff. They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders.

Making Diagnosis-

Based on Rotterdam’s Criteria:

It requires the presence of at least two of the three criteria’s

  1. Oligo/anovulation
  2. Hyperandrogenism—-clinical (hirsutism, acne) or biochemical (raised FAI or free testosterone )
  3. Polycystic appearance of ovaries on ultrasound

CAUSE

Today, chronically elevated LH and insulin resistance is considered the two main pathogenic factor in the background of increased metabolic disturbances in women with PCOS.

CURRENT ISSUES

IRREGULAR MENSTURAL CYCLES -they can appear at the time of puberty or later on wherein the periods can become irregular, or may disappear altogether. It is the high levelsof circulating androgens in body that interfere with menstural cycle. ACNE-PCOS related acne happen more often in hormone dependent areas eg lower half of face, back and neck ,are more thicker and resistant to treatment and tend to breakout just prior to periods.

HIRSUTISM-unwanted male pattern hair growth can happen because of excessive androgen.It is usually thick, coarse hair growth and can cause a great deal of distress in growing up girls

LONG TERM ISSUES

Obesity

Obesity is considered one of the most important features of PCOS. But also depends on local environmental factors, ethnic backgrounds, and lifestyle, and not on the mere presence of PCOS itself.

Childhood obesity is a well-documented risk factor for PCOS. Whether obesity leads to PCOS or whether PCOS leads to obesity is still debatable.

INFERTILITY

Women with PCOS may have reduced fertility due to the associated endocrine and gynecologic abnormalities that impact ovarian quality and function.

Some studies suggested that females with PCOS who conceive might suffer from pregnancy-related complications such as gestational diabetes, pregnancy induced hypertension, and preeclampsia to a higher extent in comparison to matched controls

Type II diabetes mellitus

PCOS confers a substantially increased risk for type 2 diabetes mellitus and gestational diabetes from early ages (Randeva et al., 2012). About 1 in 5 women with PCOS will develop type II diabetes (Dunaif, 1999) making impaired glucose tolerance a common abnormality in this disease

Cardiovascular disease

In 1992, Dahlgren et al. identified a 7 times higher risk of myocardial infarction in patients with PCOS compared to healthy controls, with significantly elevated biomarkers for CVD.

Cancer

Females suffering from PCOS present many risk factors associated with the development of endometrial cancer, such as obesity, insulin resistance, type II diabetes mellitus, and anovulation. Anovulation triggers an unopposed uterine estrogen exposure. This can subsequently trigger the development of endometrial hyperplasia and ultimately endometrial cancer. As a matter of fact, studies show that women with PCOS have a three-fold increased risk of developing endometrial cancer.

Psychological wellbeing

Psychological stress and PCOS have been shown to be intimately related. A vast number of studies showed that women with PCOS are more prone to suffer from psychological disorders such depression , anxiety, recreational drug-related incidents ,disordered eating, and psychosexual dysfunction in comparison to healthy female controls. In addition, females with PCOS have a lower self-esteem and poor body image.

MANAGEMENT

Management of PCOS requires identification and management of current symptoms ,attention to fertility and emotional concerns as well as activities to minimize the risk of future health issues .

PCOS management should be considered across the lifespan and individualised, making sure that patient priorities are identified. A team/multidisciplinary approach should be considered, where appropriate and available. Treatment usually requires the corroboration of a team that can include a family practitioner, a gynecologist, and endocrinologist, a dermatologist, a pediatrician, a psychiatrist, and a psychologist.

The keys to managing PCOS include:

  • A good understanding of how it’s caused and the effect of PCOS on the body
  • A healthy approach to eating and physical activity
  • Appropriate medical therapies

LIFESTYLE CHANGES

Eating wisely, being physically active, sleeping well, and managing your stress can help reverse the hormone imbalances at the center of polycystic ovary syndrome and the symptoms those hormone changes cause.

Weight loss is best achieved through a combination of lifestyle changes – a healthy diet and physical activity. It is not always easy to make changes to your lifestyle so that you eat more healthy foods and make exercise a regular part of life. Learning and understanding about goal setting can be helpful along with how to make changes to your behavior.

Even a 5-10% weight loss can have significant health benefits, including improved mood and fertility, more regular menstrual cycles and a reduced risk of diabetes.

MEDICAL THERAPY

These therapies may include:

  • The oral contraceptive pill
  • Insulin sensitizing drugs such as Metformin
  • Hormones that are called gonadotrophins when managing infertility.
  • Testosterone lowering drugs
  • Weight loss drugs
  • Antidepressants
  • Anti-anxiety drugs. 

INDIVIDUALIZED TREATMENT

1.Clinical hyperandrogenism (hirsutism/acne/alopecia)

  • Cosmetic options: laser hair removal, depilatory creams, threading, plucking, waxing and electrolysis
  • Pharmacological therapy options (6-12 months to see benefit):
    • COCP – (all will assist)
    • Aim for lowest effective dose
  • Combination therapy – if ≥6 months of COCP is ineffective, consider adding anti-androgen to COCP
    • Anti-androgen (eg spironolactone, usual dose 100mg-200mg daily)
    • Contraception is vital to prevent pregnancy while on anti-androgens

 

2.Menstrual cycle regulation

  • Lifestyle efforts can improve cycle regularity
  • Combined oral contraceptive pill (COCP)
  • All COCP pills increase SHBG thereby reducing free androgens; provide contraception, endometrial protection and cycle regulation (monitor glucose tolerance in those at risk of diabetes as may increase insulin resistance)
    • No COCP has been shown to be better than another
    • Cyproterone containing COCPs should be considered second-line due to increased VTE risk
  • Progestogens alone may be used cyclically or as an IUD where COCP is contraindicated or not preferred .
    • Metformin – improves ovulation, re-establishes cycles, reduces insulin resistance, reduces progression to diabetes, may prevent weight gain, but does not cause weight loss
    • Minimise side effects with starting dose 1 x 500mg daily, increase by 500mg per fortnight up to 1500mg-2000mg average dose
    • Alcohol excess should be avoided on metformin Key messages: • Women with PCOS have increased risk

Fertility

  • BMI >25 – weight loss first-line
  • 5-10% weight loss may assist in cycle control and fertility
  • Pharmacological therapies for infertility include letrozole or clomiphene, but in primary care, metformin can be started before fertility specialist referral informing women that it is not as effective
  • Referral to fertility specialist if unable to conceive at º 12 months if 35 years

Weight management

  • Monitor weight regularly, important for: º targeting prevention of weight gain in all (if a healthy weight or overweight) º achieving at least 5-10% weight loss if overweight
  • Education alone and setting unachievable goals are generally unsuccessful
  • Encourage simple behavior change – prioritization of healthy lifestyle, family support, lifestyle and exercise planning, setting of small achievable goals
  • Calorie deficit of 500-750 cal. daily required for weight loss (ie 1200-1500 cal. daily intake), with no one diet preferred
  • 250 min moderate exercise/week or 150 min vigorous exercise/week required for weight loss
  • Consider referral via team care arrangement if appropriate:

                º Dietitian (tailored dietary advice, education, and behavioral change support)

                º Exercise physiologist (exercise motivation, education)

                º Psychologist (motivational interviewing, behavior management techniques, emotional         health and motivation)

                º Group support (diet and exercise program)

 

Cardiometabolic health Screen for cardiovascular risk factors:

  • Smoking – advise cessation
  • BP: check annually
  • Lipid profile at baseline if BMI >25, then according to overall CVD risk: check every 2-4 years Diabetes:
  • 3-5 fold increased risk and earlier onset of gestational, prediabetes and diabetes in PCOS; these also occur in lean and in young PCOS women
  • Screen with OGTT, fasting glucose or HbA1c. If high risk use OGTT (eg, history of GDM, IFG, IGT, family history of diabetes, hypertension or high-risk ethnicity) º Every 1-3 years (annually if IFG/IGT)

 

Mental & emotional health

  • In women with PCOS there is a high prevalence of moderate to severe anxiety and depressive symptoms • Screen for anxiety and depressive symptoms at diagnosis
  • Eating disorders, negative body image, low self-esteem and psychosexual dysfunction should also be considered
  • If screening is positive, assess risk factors and symptoms using an appropriate assessment tool.

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