Introduction:
PCOS is one of the most common endocrine disorders in females and the most common cause of anovulatory subfertility. The prevalence is 6 to 7 % in the childbearing age group, although it differs according to the ethnicity. It is a diagnosis of exclusion (all other pathologies are to be excluded like thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinemia, androgen insensitivity syndrome, Cushing's syndrome).
Rotterdam criteria is used to diagnose the disease (presence of two of three variables):
- Irregular or absence of ovulation cycles for greater than 42 days.
- Clinical and/or biochemical signs of hyperandrogenism, acne, hirsutism, alopecia.
- Polycystic ovaries on pelvic ultrasound: 12 or more peripheral follicles, each one of 2 to 9 mm or increased ovarian volume greater than 10 ml.
What Are The Causes of PCOS?
Most of the patients show increased luteinizing hormone production. This hormone stimulates androgen production (mostly in thin patients). Thin patients can also be insulin resistant but a very small percentage (10 %).
Nearly half of the patients of PCOS are overweight (BMI greater than 30, can have increased production of androgen as well) but mainly show insulin resistance (defective insulin receptors) with compensatory hyperinsulinemia.
Hyperinsulinemia results in increased androgen production that leads to anovulation.
What Are The Investigations To be Carried Out?
The main diagnostic tests are the following -
- Transvaginal scan.
- Thyroid function test, serum prolactin, free testosterone level (day-2 menstrual day).
- FSH/LH ratio, progesterone are relatively helpful tests but not in diagnostic criteria now.
- For females nearing 40 years with PCOS with infertility and trying to conceive, the anti-Mullerian hormone is used as a potential diagnostic marker and indicator of ovarian reserves.
- In females having severe abnormal growth with hyperandrogenism and total testosterone greater than 5 mmol/l, 17-hydroxyprogesterone is advised to rule out androgen secretory tumor.
What Are The Long-term consequences of PCOS?
I. Metabolic disorders
1. Risk of developing type-2 diabetes especially in women who have the following:
a. Strong family history of type-2 diabetes.
b. Age greater than 40 years.
c. BMI greater than 25.
2. Gestational diabetes mellitus (more than 10 %).
PCOS women observe increased blood sugar levels and need investigations and referral to specialist diabetic obstetric care if abnormalities are detected.
3. Dyslipidemia.
II. Ischemic heart disease or cardiovascular accidents
PCOS women could have diabetes with or without a family history of diabetes, obesity, hypertension, hypercholesteremia, or dyslipidemia.
Increased risk of clot formation (developing atherosclerosis) can lead to MI (myocardial infarction).
III. Infertility and miscarriage
PCOS is responsible for more than two-third cases of anovulatory infertility. In case of conception, due to hormonal imbalance, miscarriages can easily happen. So, they need infertility treatment as well as conception support. Around 40 % miscarriages occur due to metabolic and endocrine factors.
IV. Endometrial cancers
Irregular or absent ovulation and oligo or amenorrhea are related to increased estrogen production that leads to endometrial hyperplasia (endometrial thickness more than 7 mm). If left untreated, it can lead to endometrial carcinoma.
How to Prevent Long-Term Consequences of PCOS?
The first step in the treatment of PCOS is by the normalization of BMI (body mass index). BMI should be normal, as both reduced as well as higher weight cause anovulation.
If the patient is underweight, she should try to balance the weight towards normal to reduce the risk of anovulation.
If the BMI is 30 or more, then this should be reduced by daily exercise, walk, aerobics, yoga, swimming, etc. Reducing weight reduces the risk of complications and there is a spontaneous resumption of ovulation and improvement of fertility.
2. Balanced healthy nutritious diet
A balanced diet with low salt, sugar, oil and spices and plenty of vegetables and fruits need to be had for a balanced weight. It will be a good input to maintain the body physiology and prevention of future consequences like hypertension, diabetes, hypercholesteremia, cardiovascular accidents, stroke, etc.
3. Reduction of insulin level
Reduction of insulin and androgen level not only normalize glucose metabolism but also increases sex hormone binding globulin (indirectly reduces consequences like abnormal body hair growth and acne).
4. Improving menstrual regulation
By regulating the menstrual cycle, ovulation chances increase with the subsequent help of normal BMI, COCP (combined oral contraceptive pills), and Metformin.
Weight loss in obese petients and normalization of weight in underweight women help to overcome hormonal imbalances and improvement of ovulation.
Combined oral contraceptive pills give hormonal support cyclically and regulate cycles and ovulation by reducing male hormones and their side effects as well.
Medications to control diabetes, more specifically Metformin, is used by many gynecologists in PCOS patients. Its mode of action is the reduction of glucose level and its production. Normal glucose level brought about by Metformin has a positive effect on the ovarian function by reducing male hormones, thus restoring menses cyclically.
Metformin is also used along with Clomiphene citrate for ovulation induction, especially in PCOS patients who have been trying to conceive for years. In few patients with high serum insulin history with infertility, it helps with conception and reduces the chances of miscarriage (if continued in early pregnancy) and ovarian hyperstimulation syndrome. Patients with high BMI do not respond well to Metformin.
All the factors that increase insulin sensitivity like Metformin, and normalization of BMI, usually help in successful IVF, increases pregnancy rate, chances of ovulatory cycles, and decrease ovarian hyperstimulation syndrome.
5. Overcome hyperandrogenic syndrome
Cosmetic laser, electrolyte treatment, waxing, threading, shaving, plucking, depilatory cream, topical facial Eflornithine (Vaniqua) help.
Hormonal treatments and medicines for PCOS also help but in the long term.
Combined oral contraceptive pills reduce androgen and increase sex hormone binding globulin. So, this indirectly reduces abnormal hair growth.
Co-cyprindiol (Ethinylestradiol and Cyproterone acetate) - it is antiandrogenic combined contraceptive that will reduce abnormal hair growth gradually.
6. Recreational activities
Recreational activities and hobbies take an important role in the maintenance of psychological and emotional well-being. So, encourage these activities in life to naturally reduce stress and anxiety from life that will indirectly affect the irregularities of your cycles. Painting, drawing, tourism, teaching children, and gardening are all very soothing activities for women. Do not underestimate these.
7. Psychological support
PCOS patients need psychological support, motivation, encouragement, to increase self-esteem to deal with side effects like obesity, infertility, abnormal hair growth, etc.
Just lifestyle modifications, healthy precautions, emotional, physical, psychosocial well-being and persistence to deal with symptoms will help reduce long-term consequences of PCOS.
A multidisciplinary team including an endocrinologist, gynecologist and obstetrician, dietitian, and physical health experts along with the support of family, partner, and siblings can help deal with this syndrome effectively.
Conclusion
Therefore, taking necessary measure to consume a healthy diet and perform regular physical activities can aid women to prevent the long-term consequences of PCOS. In addition frequently visiting the gynecologist can also aid with bettter prognosis of the condition.
