Polycystic Ovarian Syndrome (Pcos)

Polycystic Ovarian Syndrome (PCOS), Polycystic Ovarian Disease (PCOD) is a hormonal disorder that affects approximately 10-15% of women worldwide. This means that approximately 1 in every 10 women is affected by PCOS. It generally manifests as a combination of symptoms including irregular periods, infertility, typical ultrasound appearance of polycystic ovaries & excess facial/body hair/acne, or other signs of excess male hormones in the body.

It has actually taken the form of an urban epidemic, especially in women who have a sedentary lifestyle or erroneous eating habits, commonly seen in bigger cities & metros. Hence, it has become increasingly important to improve our understanding of the disease & subsequently arrive at a solution to improve the symptoms.

So let’s try to understand the basics of PCOS in this article.

What is PCOS?

Polycystic Ovarian Syndrome is a hormonal disorder which is characterized by delayed or irregular periods, Ultrasound appearance of polycystic ovaries and clinical features of excess male hormones in the body (Hyperandrogenism).

Irrespective of the extent & severity of the symptoms, PCOS is a condition that takes a huge toll on the physical & mental wellbeing and also affects the quality of life to a certain extent.

What are the Symptoms of PCOS?

It is important to remember that not all women who have a Polycystic appearance of ovaries on ultrasound will have the syndrome of PCOS and not all women who have PCOS will manifest all the symptoms of the syndrome.

Young girls & women with PCOS frequently visit the gynecologist with complaints of inability to lose weight, excess of coarse hair on the face, acne, and inability to conceive. However, the most common symptom of PCOS is irregular or delayed periods and sometimes prolonged or scanty flow during periods.

The common symptoms of PCOS are

• Husky voice, infertility
• Bad sleep quality
• Sleep apnea
• Mood changes
• Anxiety and depression.
• Delayed, irregular, scanty, early or prolonged periods
• Gaining weight that may often be difficult to lose.
• Increased body hair-Hirsutism (abnormal hair on face & body)
• Acne
• Scalp hair loss

Needless to say, PCOD can give rise to a host of problems.

What are the Causes of PCOS?

PCOS is a complex disorder and there are various factors that contribute towards its development & the severity of manifestation of the symptoms.

1. Insulin resistance: Insulin is a hormone secreted by the pancreas. It acts in the following ways

• It facilitates the movement of blood sugar into various cells of the body & also plays a role in regulating the production & function of various other hormones in the body.
• When the body tissues become resistant to the effects of Insulin, sugar molecules remain circulating in the bloodstream and are unable to enter into the blood cells. As a result, the blood sugar levels rise & the person may develop pre-diabetes or Diabetes.
• Additionally, when the body tissues become resistant, the pancreas produce more insulin to overcome that resistance & maintain the transfer of sugar molecules from the blood to the body cells. This increased level of insulin affects the ovaries & induces them to produce more of male hormones ( androgens) as compared to the female hormones.
• Simultaneously, the increased level of Insulin also decreases the production of Sex-Hormone Binding Globulin ( SHBG) from the liver, which leads to increased levels of circulating androgens which are the active form of the hormones.

All the above effects contribute towards the development & manifestation of various symptoms of PCOS. There are various theories about why Insulin resistance develops in some people and they show that increased fat distribution around the waist & upper body seems to be an important contributing factor. Stress & anxiety also play an important role.

2. Poor lifestyle: A poor lifestyle is characterized by the following

• Sedentary daily routine & lack of adequate physical activity
• Following an incorrect diet which is rich in fats, sugars, processed/packaged foods, and preservatives
• Excessive stress stimulates the production of stress hormones as well as androgens from the adrenal glands in the body and contributes to the development of symptoms of excess male hormones in PCOS
• Lack of good sleep – Research shows that poor quality of sleep & erroneous sleeping patterns are associated with obesity & Insulin resistance, both of which, play an important role in the development of PCOS

3. Genetic: Various studies have supported the role of genetic factors in the development of PCOS, which is also supported by the increased incidence of PCOS cases within certain families & cultures. However, scientists have still not been able to conclusively pinpoint the specific genes responsible for the development of PCOS and many studies highlight the importance of environmental & lifestyle factors in the development of PCOS. So, even though genetics seems to play some role in PCOS, it seems that lifestyle modifications behavioral changes can help in preventing the manifestation of the disease.

How is PCOS diagnosed?

A worldwide criterion known as the Rotterdam Criteria helps to diagnose this condition. There are three components that are included here that help define PCOS. Traditionally speaking, the presence of at least two of these criteria is required to diagnose PCOS.  

• Anovulation or oligo-ovulation: In simple language, it means either absence or delayed release of an egg from the ovary. This leads to delayed, irregular periods and sometimes prolonged or scanty flow during the periods. It also leads to difficulty in conceiving and women with anovulation/oligo-ovulation may need assistance to induce ovulation for getting pregnant.
• Signs of androgen (male hormone) excess: The biochemical or clinical evidence of excessive presence of the male hormone is a sign of PCOS. The clinical evidences of increased androgens include factors such as excessive facial & body hair, acne, scalp hairloss, increased fat distribution in waist & upper body area. The biochemical evidences include certain hormonal tests which enable us to determine the amount of male pattern hormones for eg Free & Total Testosterone, Androgen index, etc.  
• Polycystic ovaries in the Ultrasound: The ovaries may have a typical appearance showing multiple tiny cysts, which are actually partially grown ovarian follicles or eggs. The presence of 10-12 or more of these tiny cysts arranged peripherally around the ovary and an increased volume of the ovary ( > 10cc) is a feature of PCOS.

Treatment

A number of factors are taken into consideration before deciding the course of treatment for PCOD. Some of these factors are age, the severity of symptoms, your desire to achieve a pregnancy, and your overall health.

The various treatment options available in a woman with PCOS include

1. Lifestyle modifications: Even though PCOS is a complex disorder with multiple causative factors, improvement in lifestyle forms a mainstay of treatment for all women having the disease. It focuses on developing healthy habits and behavioral changes that help combat the effects of PCOS.    

• Diet control- Focus more on consuming home-cooked, healthy & hygienic food which is rich in nutrients and contains more complex carbohydrates rather than simple carbohydrates which have a high glycemic index that causes a rapid increase in your blood sugar level.
• Avoid consuming processed/packaged and junk foods that give you empty calories with minimal nutrient value.   
• Try to consume fresh fruits & vegetables that are locally grown in your region & are appropriate for the season rather than the ones which are stored in deep freeze or transported across long distances.  
• Weight loss- Weight loss, especially around the waist /trunk area goes a long way in improving the manifestations of PCOS. Try to lose at least 5% of your body weight and you will notice a significant improvement in the symptoms. 
• Exercise- A Sedentary lifestyle is the commonest factor that prompts the manifestation of symptoms of PCOS in most women. Try to include at least 45 minutes of moderate-intensity, sweat-inducing exercise in your daily routine and you will notice a positive change in the energy levels as well as the severity of disease symptoms over a span of a few weeks. You can opt for anything that suits your personality & lifestyle- brisk walking, yoga, pilates, swimming, cycling, dance, zoomba, aerobics & strength training exercises that help build your muscle & core strength. The important thing is to stay consistent & continue with your exercise schedule regardless of the busy daily life routine.

2. Hormonal pills: The management of PCOS in women who have irregular or delayed periods and are not trying to get pregnant at present includes the use of hormonal pills that contain either only progesterone or a combination of estrogen & progesterone.

• Progesterone tablets – These are given once in 2 months for a duration of 10-12 days to induce a period in girls/women who do not get a spontaneous period within 2-3 months.   
• Oral contraceptive pills- These are birth control pills that are a combination of estrogen & progesterone. They serve to regulate the estrogen/progesterone levels in the body & also decrease androgen levels. Additionally, they also serve the purpose of birth control in women who do not desire to conceive at present.

3. Medicines to help you ovulate regularly: In women who are trying to conceive, it is important for the egg to be produced & released on time every month so as to improve the chances of conception. Your doctor can prescribe you ovulation induction medications like clomiphene or letrozole after complete evaluation and help in ovulation to increase your possibility of attaining a pregnancy.

4. Insulin Sensitizers: These are medicines that improve the sensitivity of your body tissues to insulin and thus overcome the problems created due to insulin resistance. The commonest medication is Metformin which helps in the utilization of the glucose in the body and also decreases insulin resistance in body tissues thus improving the overall hormonal milieu and reducing your chances of developing diabetes.

5. Treatment of Hirsutism: Hirsutism implies the presence of excess facial & body hair in females produced due to excess male hormones ( androgens ) in the body. Medicines like spironolactone are used to decrease the levels of circulating androgens if the blood tests show increased values. In other cases, cosmetic treatments like laser therapy, tweezing, threading, waxing, etc can be used to deal with excess body hair.

6. Treatment of acne:- Maintaining good hygiene, hydration, a healthy dietary habit helps in reducing acne to a large extent. Take a diet rich in fruits, vegetables & natural fibers & consume at least 2.5 liters of fluids in a day. Avoid spicy/ oily foods & wash your face at least twice a day with mild soap. If your acne does not improve, your doctor may prescribe certain medications to reduce & treat acne.

7. Surgical interventions- If the general, conservative treatments do not work and if the symptoms are severe or if the woman is trying to conceive but not able to do so in spite of all medical measures, doctors may need to perform a minimally invasive surgery in which ovarian drilling is done to puncture the cysts and to reduce a small amount of ovarian surface tissue in order to induce ovulation and to improve hormonal balance.

Overall, PCOS is a complex disorder and there are multiple ways to deal with it. The important thing is to not lose heart, to remain consistent & to keep trying to modify your approach unless you are able to achieve & maintain the desired results.