A Glimpse at a Complex Condition: PCOS
Vocabulary-
Hirsutism: Excessive hair growth in a masculine pattern and more masculine locations (face/chin, chest, back, etc.)
Alopecia: Absence or thinning of hair where it should normally grow (scalp)
Anovulatory infertility: Infertility caused by lack of ovulation
Oligoovulation: Infrequent/irregular ovulation
Hyperandrogenism: Excess in male hormone (testosterone)
Amenorrhea: Absence of menstruation
Virilization: Development of male physical features
Endometrial Hyperplasia: Precancerous condition which includes irregular thickening of the uterine lining
Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting 6%-20% of women. This statistic is broad and skewed as there is not a general consensus regarding the diagnostic criteria a patient must meet in order to be diagnosed with PCOS. Clinical features of PCOS include menstrual abnormalities, hirsutism, acne, alopecia, anovulatory infertility, and recurrent miscarriages. The Rotterdam criteria are employed for diagnosis in adult women, requiring the presence of two out of three criteria: oligo/anovulation, hyperandrogenism, and polycystic ovaries viewed on pelvic ultrasound. In adolescent girls, the diagnostic criteria encompass menstrual irregularity, hyperandrogenism, and hyperandrogenemia, with no necessity for pelvic ultrasound. The Rotterdam criteria are the most widely accepted criteria for diagnosing PCOS but there is some argument in the validity of this tool as it includes a very narrow range of criteria when PCOS, as an endocrine disorder, has many different manifestations from patient to patient.
Endocrine features include elevated androgen, luteinizing hormone, estrogen, and prolactin levels. Metabolic features involve insulin resistance, obesity, lipid abnormalities, and an increased risk of type 2 diabetes. Transvaginal ultrasound is the gold standard for diagnosing polycystic ovaries.
Reasons women with PCOS seek medical care include infertility (74%), menstrual irregularities (29% with irregular bleeding, 51% with amenorrhea), and androgen excess (69% with hirsutism, 21% with virilization). Virilization, characterized by voice deepening and increased muscle mass, may indicate a tumor rather than PCOS.
Treatment strategies vary based on symptoms-
Infertility: Ovulation induction is a common approach. Ovulation induction with letrozole can be beneficial, while chronic anovulation necessitates monitoring for endometrial hyperplasia and carcinoma.
Menstrual irregularity: Oral contraceptives or progestin can be used. Biopsy is recommended if no uterine bleeding occurs for over a year. Oral contraceptives, specifically those containing cyproterone acetate or drospirenone, can help manage androgen excess.
Hirsutism: Management involves oral contraceptives or spironolactone.
Obesity is prevalent in 60%-70% of women with PCOS, contributing to increased insulin resistance. Addressing insulin resistance is crucial, as it correlates with hyperandrogenism and cardiovascular risk. Weight reduction, achieved through a low-carb, low-fat diet and consistent exercise, has been shown to improve the endocrine profile and increase the likelihood of ovulation and pregnancy. Metformin is a medication that is commonly used to treat insulin resistance though it is not a safe option during pregnancy.
This is only a brief glimpse into an extremely complex condition. PCOS is a multifaceted condition affecting women across various life stages. A comprehensive approach to treatment including, addressing hormonal, metabolic, and lifestyle factors, is crucial for effective management and improved quality of life for individuals with PCOS.
