Polycystic Ovarian Syndrome (PCOS) is the most prevalent endocrine disorder among women of reproductive age, affecting 5% to 10% of women globally. The occurrence of PCOS is significantly higher among South Asian women, particularly Pakistani women, with a prevalence of 52%, compared to 20-25% in the white population in the UK.Pakistan exhibits an infertility rate of 21.9%, with PCOS accounting for 38.5% of the cases.
Clinical Features
- Irregular menstrual cycle
- Excessive hair growth
- Weight gain or difficulty in losing weight
- Cystic acne
- Male pattern baldness
- Skin tags
Associations
- Insulin resistance: About one-third to two-third women with PCOS have impaired glucose tolerance. Insulin resistance means that body doesn’t respond to insulin resulting in increased blood glucose and insulin levels. This significantly increases the risk of type-2 diabetes.
- Metabolic Syndrome: Metabolic syndrome comprises high blood pressure, high triglycerides level, insulin resistance, abdominal obesity and low HDL levels, substantially increasing the likelihood of cardiovascular diseases, type 2 diabetes and stroke in women with PCOS.
- Obesity: High insulin levels result in elevated hunger, increased fat storage and decreased breakdown of lipids.
- Endometrial Cancer: The primary mechanism through which PCOS heightens the risk of endometrial cancer is by subjecting the endometrium to prolonged exposure to unopposed estrogen resulting from anovulation. This extended exposure can induce endometrial hyperplasia, potentially culminating in endometrial cancer.
- Obstructive Sleep Apnea: An essential aspect lies in the correlation between PCOS and obesity, where surplus weight can result in the buildup of fat around the neck region, potentially obstructing the upper airway during sleep.
- Depression and Anxiety: Research indicates a higher prevalence of depressive symptoms among women with PCOS compared to non-BMI-matched counterparts. Moreover, PCOS women also exhibit elevated rates of major depression, recurrent depression, and suicide attempts.
- NAFLD and NASH: Women diagnosed with PCOS face a threefold higher risk of developing non-alcoholic fatty liver disease (NAFLD), a condition linked to excess androgen levels and reduced sex hormone-binding globulin (SHBG).
Diagnosis
A diagnosis of PCOS typically involves excluding other potential causes of similar symptoms and meeting at least two of the following three criteria:
1. Irregular or infrequent menstrual cycles, indicating irregular ovulation.
2. Elevated levels of “male hormones” (androgens) in blood tests, such as testosterone, or signs of excess male hormones, even if blood test results are normal.
3. Presence of polycystic ovaries observed in scans. In individuals who are more than 8 years past menarche, the criteria for polycystic ovarian morphology (PCOM) include:
- Having a follicle number per ovary (FNPO) of at least 20 in one or more ovaries, and/or
- Having a follicle number per ovarian section (FNPS) of at least 10 in one or more ovaries, and/or
- Exhibiting an ovarian volume of at least 10 mL, with the condition that no corpora lutea, cysts, or dominant follicles are present.
As only two criteria are required for a diagnosis, an ultrasound scan may not always be necessary to confirm the condition.
Management
Lifestyle Modifications
- Regular Exercise: It helps reduce weight, improve insulin resistance and balance the levels of androgens.
- Balanced Diet: High fibre diet such as beans, lentils, chia seeds, vegetables helps fight insulin resistance, foods with anti-inflammatory properties like tomatoes, nuts, olive oils, fruits, green leafy vegtables are benefical in pcos.
- Avoid processed food (cakes, candies, pastries), pasta, white rice, sodas, red meat, saturated fat, and fried stuff.
- Do regular yoga and meditation.
Supplements
The following supplements can prove beneficial for pcos after consultation with a doctor.
- Curcumin: Curcumin is also known to induce ovulation and enhance the biochemical profile of patients with PCOS
- Vitamin D: Many women with PCOS have low vitamin D levels, and supplementation may help improve insulin sensitivity and regulate menstrual cycles.
- Inositol: Inositol, particularly myo-inositol and D-chiro-inositol, may help improve insulin sensitivity and ovarian function in women with PCOS.
- Omega-3 Fatty Acids: Omega-3 fatty acids, found in fish oil supplements, may help reduce inflammation and improve lipid profiles in women with PCOS.
- Magnesium: Magnesium supplementation may help improve insulin sensitivity and reduce inflammation in women with PCOS.
Pharmacological Interventions
- Hormonal Contraceptives
- Metformin
- Treatment for infertility:
- The primary treatment for infertility in PCOS patients is typically clomiphene citrate.
- However, recent research suggests that estrogen modulators like letrozole can also be effective in treating ovulatory infertility. A double-blind, multicenter trial funded by the National Institutes of Health found that letrozole, compared to clomiphene, resulted in higher rates of live births and ovulation among infertile women with PCOS.
- Additionally, metformin is recommended as an adjunctive treatment for infertility, particularly in obese patients, to help prevent ovarian hyper stimulation syndrome during in vitro fertilization procedures.
- Treatment for Hyperandrogenism:
- The initial treatment for hirsutism is typically low-dose oral contraceptives (OCPs), which have both contraceptive and ant androgenic properties. These medications effectively reduce androgen levels and are particularly beneficial when combined with anti-androgenic drugs, as the latter can be highly teratogenic and require reliable contraception.
- Mild cases of hirsutism may be managed with OCPs alone. Spironolactone is commonly prescribed as an adjunct anti-androgen medication after OCPs. It works by suppressing testosterone levels and also offers additional cardiovascular benefits compared to OCPs alone.
- Combining spironolactone with metformin has been shown to be more effective than monotherapy with either drug alone, leading to improvements in menstrual cycles, glucose levels, and testosterone levels.
Other Treatments Options to improve Insulin Sensitivity include:
- GLP-1 agonists
- DPP4 inhibitors
- SGLT2 inhibitors
- Myoinositol
- Peroxisome proliferator-activated receptor gamma (PPARg) agonist
