Polycystic ovary syndrome (PCOS)

Endocrine disorders among women are of various types, but the most common is polycystic ovary syndrome (PCOS), which is basically an inherited disorder and can be received from either parent. The chances of developing this disorder vary from 5 to 10% among women in the age group 12 to 45 years, resulting in female subfertility. This endocrine disorder can be identified by anovulation that is diagnosed by irregular menstruation, amenorrhea, polycystic ovaries, ovulation-related infertility, excessive secretion of androgen hormones causing hirsutism, and acne. High cholesterol level, type 2 diabetes, insulin resistance are other known symptoms. All of these symptoms vary between different people. The disorder is known by other names such as polycystic ovarian disease, functional ovarian hyperandrogenism, ovarian hyperthecosis, and Stein-Leventhal syndrome. A polycystic ovary has an abnormal number of eggs that can be seen near its surface looking like cysts.

Polycystic ovary syndrome is generally described by two definitions. The first definition was given by NIH or NICHD in 1990 which suggests that if a woman suffers from oligoovulation, she shows signs of excess androgens and other entities that result in polycystic ovaries, then the woman suffers from this endocrine disorder. The second definition was given at an ESHRE / ASRM sponsored workshop held in Rotterdam in 2003 which predicts that if a woman suffers from oligoovulation or anovulation, has excess androgenic activity and symptoms of polycystic ovary, then she suffers from polycystic ovarian disease. The second definition seems to be broader and more acceptable. The main symptoms of PCOS include menstrual disorders, mainly amenorrhea and oligomenorrhea, but other menstrual disorders can also arise. Chronic anovulation causes infertility. High levels of androgens cause acne and hirsutism. Hypermenorrhea and other symptoms may also appear. About three-quarters of women with this endocrine disorder generally have hyperandrogenemia. Central obesity and insulin resistance are also noted. Serum insulin and homocysteine ​​levels are significantly higher in women with this disease.

It is not always necessary that women who suffer from polycystic ovary syndrome (PCOS) can have polycystic ovaries and similar is the condition that all women with polycystic ovaries may not suffer from this syndrome. The syndrome can be easily diagnosed using a pelvic ultrasound, but other diagnostic tools are also available. The individual’s history based on menstrual pattern, obesity, hirsutism, and lack of breast development can help the medical professional. A gynecological ultrasound may be performed which helps in the detection of small ovarian follicles. These small follicles are believed to form due to impaired ovarian function where ovulation has not taken place due to the absence of menstruation. In a normal menstrual cycle, a single egg is released from the dominant follicle. After ovulation, the remnant of the follicle develops into a characteristic structure known as the corpus luteum formed by the action of progesterone. This structure finally disappears after 12-14 days. In PCOS, although several follicles form, none of them grow more than 5-7 mm in length and fail to enter the preovulatory stage of the menstrual cycle. According to the Rotterdam criteria, there must be 12 or more than 12 small follicles detected on ultrasound. These small follicles are generally present near the periphery of the ovarian wall giving it the appearance of a pearl necklace. The ovary enlarges and reaches a size that is 1.5 to 3 times its normal size and this is due to the presence of these abnormal follicles.

Laparoscopic examinations show the presence of a smooth white outer surface of the ovary. Serum (blood) levels of androgens specifically androstenedione and testosterone are elevated. Dehydroepiandrosterone sulfate levels are also higher. Free testosterone levels are also high and give the best clue about the presence of this syndrome. The free androgen index of the ratio of testosterone to sex hormone binding globulin (SHBG) is generally higher, but is a poor indicator. Some blood tests are also suggested, but they are not good indicators of the diagnosis of PCOS. The ratio of LH (luteinizing hormone) to FSH (follicle stimulating hormone) is greater than 1: 1 as assessed on the third day of menstruation. Among obese women, levels of sex hormone binding globulin (SHBG) are generally low. Fasting biochemical screening and the individual’s lipid profile can be performed while looking for this syndrome. A 2-hour oral glucose tolerance test (GTT) can be performed on suspected individuals indicating impaired glucose tolerance in 15-30% of patients with this syndrome. Insulin resistance is very commonly seen in patients with PCOS. Other clinical disorders can also be associated with menstrual abnormalities, namely Cushing’s syndrome, hypothyroidism, congenital adrenal hyperplasia, and pituitary disorders.

Polycystic ovary syndrome (PCOS) is a generically inherited condition. It is inherited in an autosomal dominant system with a higher risk of occurrence in women. The chances of inheriting the gene responsible for this syndrome are 50% if the father is a carrier of the gene. Although the gene responsible for this syndrome can be inherited from either the father or the mother and the gene can be passed on to the sons, the symptoms can only appear in the daughters. The gene responsible for this disorder has not yet been identified. Polycystic ovaries generally develop when the ovaries are stimulated to produce excessive amounts of male hormones, particularly testosterone. This can occur due to the release of excessive amounts of luteinizing hormone (LH) from the anterior pituitary gland or elevated levels of insulin in the blood of women who are sensitive to insulin or reduced levels of sex hormone binding globulin (SHBG) in blood resulting in a higher level of free androgens. The syndrome has acquired its polycystic name due to the resemblance of the small follicles to cysts. The follicles develop from the primordial follicles, but their development ceases in the antral stage due to impaired ovarian function. These cysts, like follicles, are arranged on the periphery of the ovarian wall. Most patients with this disorder generally show insulin resistance and this can cause abnormalities similar to those seen in the hypothalamic-pituitary-ovarian axis.

The symptoms of polycystic ovarian disease are very complex and may not be the same for all patients. In many cases it can be characterized by hyperandrogenism and insulin resistance. Most cases of this disease have a genetic basis. Excess amounts of adipose tissue in obese people also increase androgen and estrogen levels. Adipose tissue carries an enzyme identified as aromatase that is involved in the conversion of androstenedione to estrone and testosterone to estradiol. Hyperinsulinemia causes an increase in the GnRH pulse rate, increased ovarian androgen production, decreased follicular maturation, and decreased levels of sex hormone-transporting globulin that ultimately result in polycystic ovarian disease. Chronic inflammations can also cause this syndrome. A study conducted in the United Kingdom indicated that the incidence of polycystic ovarian disease is higher in lesbian women than in heterosexual women. Medications given to patients with this disease generally focus on lowering insulin levels, restoring fertility, treating hirsutism or acne, and preventing endometrial hyperplasia, endometrial cancer, and restoration of the regular menstrual cycle. In cases where the disease is associated with obesity, weight loss is the effective strategy for the initiation of regular menstruation. A low-carbohydrate diet and regular exercise can help you lose weight.

All women with PCOS may not face the difficulty of getting pregnant, only those with anovulation can cope with the problem. Patients with anovulation problem can be treated with injections of clomiphene citrate and FSH. Patients who do not give positive results with clomiphene and FSH treatments are treated with assisted reproductive technology procedures such as controlled ovarian hyperstimulation with injections of follicle stimulating hormone (FSH) followed by in vitro fertilization (IVF). Surgery is not usually done in the case of the polycystic ovary, but a laparoscopic procedure known as an ovarian drilling is usually done. Hirsutism can be treated with an effective standard birth control pill. The key ingredient in birth control pills is cyproterone acetate, which is a progestin. This compound has antiandrogenic action and blocks the activity of male hormones that are responsible for acne and unwanted hair growth on the face and body. Other medications that have antiandrogenic effects include flutamide and spironolactone which can effectively reduce hirsutism. Spironolactone is the most widely used drug in the United States. Menstrual problems can be regulated through the use of birth control pills, but these drugs can cause additional problems if they are continued for a long time. Two isomers of inositol, namely D-chiro-inositol and myoinositol, have shown promising results against this syndrome.

Women with PCOS are at risk for endometrial hyperplasia and endometrial cancer. These clinical manifestations can arise due to excessive accumulation of the uterine lining and the absence of progesterone, which is responsible for the prolonged stimulation of uterine cells by estrogen. These symptoms establish a positive background for the development of other health problems such as obesity, hyperinsulinemia, hyperandrogenism, type 2 diabetes, and insulin resistance. A 2010 study highlighted that women with polycystic ovarian disease are at high risk of being affected by type 2 diabetes and insulin resistance. High blood pressure, depression or depression with anxiety, miscarriage, excessive weight gain, cardiovascular disease, acanthosis nigricans, autoimmune thyroiditis are other risks associated with this syndrome.