PCOD – making a correct diagnosis

Ever so often we come across a girl who is obese or has irregular periods or excessive facial / body hair or acne and we are quick to jump to a diagnosis and form an opinion regarding her appearance or medical condition. A Google search for these conditions would probably suggest that they point towards the diagnosis of PCOD ( Polycystic Ovarian Disease) . As a result, many girls /women are labelled as having PCOD and receive random treatments through self medication or the ‘well wishing’ relatives & friends.

Polycystic Ovarian Disease ( PCOD ) is a hormonal disorder characterized by irregular periods/ infertility/excess male hormones in the body & by a typical appearance of ovaries seen on Ultrasound. The manifestations of excess male hormones in the body may vary from having excess facial/body hair , acne, scalp hair loss etc. Besides, there may be increased waist & abdominal circumference, presence of thick & rough skin at the back of neck, inability to lose weight and many other symptoms.

Interestingly, not all of the above symptoms are required to be present to diagnose a girl/woman with PCOD. Most girls would have a varying combination of the above symptoms and each of these symptoms could be of variable severity. Moreover, not all the girls who are overweight or have irregular periods or excess facial hair would have PCOD. There could be other hormonal problems or health conditions leading to the above symptoms.

Confusing, isn’t it? Well yes, PCOD is a complex disease and as such, the criteria for diagnosis have also been constantly evolving & changing. The most widely accepted criteria for diagnosing PCOD is Rotterdam’s criteria which was proposed in 2003.

The Rotterdam Criteria

Rotterdam criteria is the most widely used method for the diagnosis of PCOS. It includes the following three criteria:

• Hyperandrogenism (Excess of male hormones in the body): The androgen hormones are responsible for the development and maintenance of male features in the body. Girls who have an excess of these hormones may have features like increased coarse hair growth on the face & body (hirsutism), loss of scalp hair, acne, etc. The levels of these hormones in the body can also be detected by simple blood tests like Free & Total Testosterone levels, Free Androgen Index, and a few other tests. So, the assessment of hyperandrogenism may be based on the presence of either the physical features or the blood test values.
• Anovulation / Oligo-ovulation or irregular menstrual cycles: The absence or delayed release of an egg from the ovary is called anovulation/ oligo-ovulation. This is characterized by delayed, or irregular periods which may have either scanty/prolonged or heavy blood flow.
• Ultrasound diagnosis: The polycystic ovaries can be visualized during an ultrasound. The ultrasound criteria require that the ovary should have 12 or more follicles whose diameter should range from 2-9 mm in diameter. In addition, an ovarian volume of 10 cm3 or more may be present.

According to the Rotterdam criteria, at least two of the above-mentioned criteria need to be present to make a diagnosis of PCOS.

Additionally, it is important to exclude other causes & disease conditions that may lead to the development of similar symptoms.

Ruling out other conditions

PCOS is challenging to diagnose because some of its symptoms could be caused by a variety of other hormonal disturbances or disease conditions. Heavy menstrual bleeding, for example, can be caused by uterine fibroids, polyps, adenomyosis, bleeding disorders, certain drugs, or pelvic inflammatory disease. Similarly, delayed periods could be an outcome of thyroid imbalance, premature ovarian failure, Pituitary gland disorder, stress, eating disorders, etc. Therefore, before a precise diagnosis of PCOS can be made, it is important to rule out a number of other diseases that might cause similar symptoms of PCOS. These include the following conditions:

• Hyperprolactinemia- Excess of Prolactin hormone production by the Pituitary gland.
• Thyroid disorders- Excess or deficiency of thyroid hormones.
• Cushing’s syndrome- Excess of Cortisol hormones.
• Congenital adrenal hyperplasia- A genetic disorder of Adrenal glands.
• Hypogonadotropic hypogonadism- Disorder of Hypothalamus & Pituitary gland in the brain.
• Androgen secreting tumors- Any tumor in the body which produces male hormones.

Diagnosis of PCOS in adolescents

During the growing up years, girls go through so many changes in their bodies, and some resemble PCOS. However, it doesn't necessarily mean that your child is suffering from PCOS. It is normal to have delayed periods for the first two years after menarche ( onset of menstrual cycles in a girl). Similarly, the ultrasound may normally show multiple follicles/tiny cysts in ovaries for the first couple of years. So, ideally speaking, doctors generally refrain from labeling a girl as having PCOD even if the ultrasound shows Polycystic ovaries or she has irregular/delayed periods. Experts in the field have given out the following recommendations which can help correctly determine whether or not there is a problem with an adolescent’s ovulatory function

Irregular periods

• A recurrent gap of more than 90 days between two menstrual cycles in the first two years after menarche.
• A recurrent gap of less than 21 days or more than 45 days between menstrual cycles two or more years after getting periods.
• If the periods do not begin by the age of 15 years or within 2 to 3 years following breast development.

Androgen excess

• Symptoms such as severe acne or hirsutism can occur due to excess androgen in the body.
• Biochemical hyperandrogenism that can be confirmed using validated blood tests.

So, evidence of dysfunction of ovaries and excess androgens in the absence of other causative factors is currently used to diagnose PCOS in adolescents. Some experts also suggest adding other criteria of demonstrating Insulin resistance to confirm the diagnosis of PCOD in adolescents.

So, let your daughters enjoy their golden years. Do not worry excessively about their PCOS like symptoms in the first few years. However, if symptoms persist for more than two years, it could signal towards a problem and you should seek a medical opinion for proper diagnosis & treatment.

Diagnosis of PCOS at perimenopause and menopause

PCOS and perimenopause (the time when the body is transitioning to menopause) share many common symptoms. These include

• Menstrual irregularities.
• Mood swings.
• Difficulty sleeping.
• Weight gain.
• Hair thinning.
• Unexpected hair growth on the body.

Hence, a new diagnosis of PCOS during perimenopause can be difficult. If you are under the assumption that your PCOS will be cured after menopause, then we are sorry to disappoint you. Menopause doesn't cure PCOS. It simply alters the manifestations of the disease and the symptoms may be different. Being a lifetime disorder, PCOS has various consequences that might affect your long-term health; managing the symptoms and discussing any concerns with your doctor is therefore critical at all times.

Arriving at the correct diagnosis of PCOS may require various tests. At times, you may feel that you are being overburdened with so many medical tests, but these are necessary to diagnose PCOS correctly. Some of these tests include

• Tests to check your androgen levels.
• Tests to rule out deficiencies.
• Fertility tests.
• Test to rule out other health disorders that can cause symptoms similar to PCOS.
• Tests to check for Insulin resistance.

Making the correct diagnosis of PCOS is highly crucial as this will help determine the best treatment plan for you. Underdiagnosing PCOS could lead to serious health issues in the future, such as diabetes, hypertension, and heart disease. Over diagnosing, on the other hand, could lead to unnecessary psychological stress for the person.