PCOS Polycystic Ovarian Syndrome

Article by Dr Jothi Kumar

PCOS Polycystic Ovarian Syndrome

Dr Jothi Kumar

Obstetrician & Gynaecologist
University of Singapore, Faculty of Medicine
Monash University, Melbourne, Australia
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PCOS is a condition affecting women where an underlying hormone or endocrine dysfunction causes abnormalities in ovulation leading to irregular, long menstrual cycles. It may be associated with excessive weight gain, excessive bodily hair growth and acne. An ultrasound examination of the ovaries will generally show the presence of multiple small cysts in these women - hence, reference to the term poly (multiple) cystic ovarian syndrome to describe this condition. The exact cause of the underlying dysfunction in ovulation in

PCOS is not well established. Some postulate that this may be a genetic disorder. Others propose that endocrine disturbances involving the ovary and the hypothalamus-pituitary glands, which are modulated by systemic disorders such as peripheral insulin resistance and hyperinsulinemia are involved. Although PCOS cannot be prevented, weight reduction has been shown to reduce the severity of the symptoms of PCOS, since obesity is independently associated with hyperinsulinemia.

Women with PCOS very often have irregular, long menstrual cycles with heavy menstrual flow. This can disturb their normal social activities and be disruptive at work, too. If there is associated excessive weight gain, excessive bodily hair and acne, it can affect their self-esteem and become socially embarassing to deleteriously affect their daily life-style.

PCOS has a deleterious effect on fertility, since the underlying derangement causes ovulation not to occur regularly every month. Consequently, the chance of pregnancy occurring naturally is significantly reduced in women with PCOS.  Spontaneous miscarriage rate is also higher in PCOS women.

Treatment protocols to manage women with PCOS comprise a multi-disciplinary team approach involving the gynaecologist, endocrinologist, physiotherapist and dietician. The specific treatment program will depend on the main presenting complaint. Nevertheless, reduction of weight by exercise and diet-control are the first-line fundamental intervention, irrespective of their presenting symptoms.

Where infertility is the primary issue, in addition to the standard investigations of the male and female partners, ascertaining if the female has hyperinsulinemia is important. If present, use of an oral insulin-sensitising agent like Metformin to reduce blood insulin levels before commencing ovulation induction drugs such as Clomiphene citrate or exogenous gonadotrophins, is advisable. Intra-Uterine Insemination (IUI) and In-Vitro Fertilization (IVF) are also used to manage infertility associated with PCOS.

Where irregular, long menstrual cycles with heavy menstruation is the primary complaint, ensuring regular shedding of the uterine endometrium with the use of progestagen drugs will reduce the long-term risk of developing endometrial hyperplasia and carcinoma.

Where excessive hair growth (hirsutism) and acne are the predominant complaints, cosmetic treatments are generally indicated. If associated with hyperandrogenism (excessive male hormones in the blood), use of anti-androgen drugs may have additional beneficial effects.

PCOS women who become pregnant are at a higher risk of spontaneous first-trimester miscarriage and developing gestational diabetes mellitus (GDM) and hypertension. Routine screening of all pregnant women with PCOS for GDM with an oral Glucose Tolerance Test (GTT) is advised.

If left untreated, PCOS can lead to a number of metabolic disorders in the future. These include impaired glucose tolerance/Type II diabetes mellitus, hyperlipidaemia, atherosclerotic cardiovascular disease, hypertension, endometrial hyperplasia and carcinoma, and other disorders associated with the Metabolic X Syndrome. Hence, long-term management of PCOS women, particularly obese women, require ongoing survelliance to detect these disorders.

 

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