PCOS

Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting women of reproductive age, characterized by a combination of symptoms and physical findings related to hormonal imbalances.

Causes

  • Genetic Factors: There’s a hereditary component, as PCOS tends to run in families.
  • Insulin Resistance: High insulin levels might increase androgen production, causing difficulties with ovulation.
  • Hormonal Imbalance: Elevated levels of androgens (male hormones) interfere with the ovarian cycle.
  • Inflammation: Women with PCOS often have increased levels of inflammatory markers.

Diagnosis

  • History
    • Menstrual Irregularities: Infrequent, irregular, or prolonged menstrual cycles.
    • Hyperandrogenism: Excess hair growth (hirsutism), severe acne, or male-pattern baldness.
    • Weight Gain: Often, but not always, associated with being overweight or obese.
    • Infertility: Difficulty conceiving due to irregular ovulation or anovulation.
    • Symptoms of Insulin Resistance: Including skin changes like acanthosis nigricans.
  • Physical Examination
    • Pelvic exam: To check for any abnormalities in the reproductive organs.
    • Dermatological exam: For signs of hirsutism, acne, or other skin changes like acanthosis nigricans
  • Investigations
    • Blood Tests: To measure hormone levels (testosterone, LH, FSH, prolactin, etc.), fasting glucose, and insulin levels.
    • Ultrasound: To check the appearance of ovaries and the thickness of the uterine lining. Polycystic ovaries have a “string of pearls” appearance with multiple follicles.

Differential Diagnosis (DDx)

  • Thyroid Disorders
  • Cushing’s Syndrome
  • Adrenal Hyperplasia
  • Hyperprolactinemia

Management

  • Lifestyle Changes: Weight loss through diet and exercise for overweight individuals can improve symptoms and insulin resistance.
  • Medications for Hyperandrogenism:
    • Birth control pills to regulate menstrual cycles and reduce androgen levels;
      • COCP ie 
        • Ethinyloestrodiol/Cytoproterone (Dianne)
        • Ethinyloestradiol/Drospirenone (Yaz 20, Yasmin 30 Ethinyloestradiol)
      • Progestin only for 10 days in the second half of cycle ie
        • Medroxyprogesterone acetate
        • Norethisterone
    • Anti-androgen medications like spironolactone.
  • Medications for Insulin Resistance: Metformin to improve insulin sensitivity.
  • Fertility Treatments: Clomiphene or letrozole for ovulation induction in women trying to conceive.
  • Hair Removal Treatments: Laser therapy or creams for excessive hair growth.
  • Management of Associated Conditions: Treatment for associated health issues like diabetes, high blood pressure, and high cholesterol.
  • Monitoring and Follow-up
    • Regular monitoring of menstrual cycle, weight, and symptoms.
    • Periodic assessment of glucose tolerance and lipid profile.
  • Referral
    • Consider referral to an endocrinologist or a fertility specialist for complex cases or when fertility is a concern.
  • Patient Education
    • Educating patients about the nature of PCOS, its impact on fertility, associated risks like type 2 diabetes and cardiovascular disease, and the importance of lifestyle management.

PCOS is a multifaceted condition with a wide range of manifestations, and its management often requires a multidisciplinary approach. Individualizing care based on the patient’s symptoms, metabolic profile, and reproductive goals is crucial.

PCOS and the Rotterdam Criteria

The Rotterdam criteria were established in 2003 during a consensus workshop in Rotterdam, and they are used for the diagnosis of Polycystic Ovary Syndrome (PCOS). According to these criteria, to be diagnosed with PCOS, a woman must meet at least two of the following three criteria:

  1. Oligo-ovulation or Anovulation: This refers to irregular or absent ovulation, often resulting in irregular menstrual cycles. Typically, women with PCOS might have fewer than eight menstrual cycles a year or cycles that are longer than 35 days.
  2. Clinical and/or Biochemical Signs of Hyperandrogenism: Clinical signs include hirsutism (excessive hair growth in areas where men typically grow hair, such as the face, chest, and back), acne, and male-pattern baldness. Biochemical signs refer to elevated levels of androgens (like testosterone) in blood tests.
  3. Polycystic Ovaries on Ultrasound: The ovaries often appear enlarged and contain many small fluid-filled sacs (follicles) surrounding the eggs. According to the Rotterdam criteria, the presence of 12 or more follicles in one ovary measuring 2-9 mm in diameter and/or increased ovarian volume (>10 mL) is indicative of polycystic ovaries.

Remember, a diagnosis of PCOS based on the Rotterdam criteria doesn’t require the presence of polycystic ovaries on ultrasound. A woman can still be diagnosed with PCOS even if she doesn’t have polycystic ovaries, as long as she meets the other two criteria.

The Rotterdam criteria broadened the diagnostic categories for PCOS, making it possible for more women to be diagnosed and treated. However, because it’s a syndrome with a range of symptoms, PCOS diagnosis can still be complex, and it’s crucial to rule out other conditions that might mimic PCOS.