Polycystic ovarian syndrome

Dr Louise Johnson expands on polycystic ovarian syndrome and the risk of it leading to Type 2 diabetes.

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Polycystic ovarian syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. It was described in 1935 by Stein and Leventhal.

Systematic screening of women according to the National Institute of Health diagnostic criteria estimate that 4 to 10% of women of reproductive age suffer from PCOS.¹

Understanding PCOS

PCOS is a hormonal imbalance when the ovaries create excess androgen hormones.

The diagnosis of PCOS can follow one of three guidelines:

National Institute of Health criteria:

1. Hyperandrogenism (high male hormone)
2. Menstrual irregularity

Androgen Excess PCOS Society criteria:

1. Hyperandrogenism
2. Menstrual irregularity or polycystic ovaries on ultrasound

Rotterdam criteria (2 of 3):

1. Hyperandrogenism
2. Menstrual irregularity
3. Polycystic ovaries on ultrasound

In polycystic ovaries there are small follicle cysts (fluid filled sacs with immature eggs) visible on your ovaries on ultrasound due to lack of ovulation (anovulation). This is one of the most common causes of infertility in women.

Signs of PCOS

• Irregular periods which include missing menstruation or heavy bleeding.
• Abnormal hair growth on arms, chest and abdomen. This is called hirsutism and affects up to 70% of women with PCOS.
• Acne especially on face, chest and back. This may continue past teenage years and is difficult to treat.
• Obesity is common in 40 to 80% of women with PCOS and they have trouble maintaining a healthy weight.
• Darkening of skin in the folds of the neck, armpits and groin and under breasts. This is called acanthosis nigricans.
• Cysts on ovaries that appear larger or with many follicles (egg sac cysts) on ultrasound.
• Skin tags in armpits or on the neck.
• Thinning hair or patches of hair loss.
• Infertility is caused by PCOS.

What are the main causes of PCOS?

The exact cause is unknown. Genetics may play a role. Several other factors, most importantly obesity, also play a role. Other factors that play a role are:

1. Higher levels of androgens (male hormones)
2. Insulin resistance
3. Low grade inflammation

How is PCOS diagnosed?

Clinical history of abnormal menstrual cycle.

Signs and symptoms as discussed above.

High levels of testosterone and luteinizing hormone (LH).

On ultrasound more than 12 follicles in each ovary.

Follicle size between 2 and 9mm.

Morbidities associated with PCOS

Obesity

This is one of the most common features of PCOS and varies between 61 and 76%. Childhood obesity is a well-documented risk factor for PCOS.

Insulin resistance

This is considered the main pathogenic factor in the background of increased metabolic disturbances in women with PCOS which can explain high androgen levels, menstrual irregularity and abnormal blood lipid levels.³

Type 2 diabetes

PCOS confers a substantially increased risk for Type 2 diabetes and gestational diabetes from early ages. About 1 in 5 women with PCOS will develop Type 2 diabetes.

Cardiovascular disease

In 1992 Dalhgren et al² identified a 7 times higher risk of heart attack in women with PCOS compared to healthy people. More recent data shows higher burden of atherosclerosis and early onset cardiovascular dysfunction and heart vessel calcifications.

Infertility

In a 2015 study it was shown that infertility is 10-times more common in women with PCOS than in healthy controls. Women who conceive with PCOS might suffer from pregnancy-related complications, such as gestational diabetes and pregnancy-induced hypertension. Concerning the effects of the foetus, women with PCOS are 2.5 times at a higher risk of giving birth to a small for gestational age child.

Cancer

Females suffering from PCOS are at risk for endometrial cancer. Studies show a three-fold increase risk to develop endometrial cancer.

Psychological well-being

Women with PCOS are more prone to suffer from depression, anxiety, disordered eating and psychosexual dysfunction. It’s worth noting that obesity, acne, hirsutism and irregular menstrual cycles, all associated with PCOS, are major contributors to the psychological stress that the patients experience due to the challenging of the female identity and her body image.

Treatment

The management of PCOS targets the symptomatology for which patients usually present: anovulation, infertility, hirsutism and acne.

Lifestyle

Lifestyle modifications, such as exercise and a calorie-restricted diet, are considered as a cost-effective first-line treatment. Excessive weight is associated with adverse metabolic and reproductive health outcome. For instance, female fertility significantly decreases with body mass index (BMI) more than 30.

Multiple studies show that weight decrease as little as 5% regulates menstrual cycle, improves fertility, reduces insulin and testosterone levels, decreases acne and hirsutism and benefits psychological well-being.

Medical treatment

1. Oral contraceptive pills

Oral contraceptive pills are the most used medication for the long-term treatment of women with PCOS. It’s recommended for regulating of menstrual cycle and decrease of testosterone levels as first-line treatment. A minimum of six months on oral contraceptives is usually required to obtain satisfactory results against acne and hirsutism.

2. Metformin

Metformin is an oral antidiabetic biguanide drug that acts on suppressing glucose production from the liver and increasing peripheral insulin sensitivity. The use of metformin in women with PCOS decreases insulin resistance, reduces testosterone levels and improves glucose managing in the body.⁴

Screening recommendations

Screening for Type 2 diabetes

Women with PCOS should be routinely screened for Type 2 diabetes. Studies have shown that measuring only fasting glucose in patients with PCOS miss up to 80% of prediabetics and 50% of diabetics.

Current guidelines suggest screening women with PCOS using an oral glucose tolerance test every three years. Risk factors that require screening more often are:

• Family history of diabetes
• Hypertension medication use
• Smoking
• Increased waist circumference more than 80cm in females
• Physical inactivity

Screening for cardiovascular disease

Women with PCOS should be screened regularly for risk factors such as:

• Increased waist circumference
• Smoking
• Blood pressure
• Abnormal cholesterol profile (increase triglycerides and low HDL)

 Screening for psychological well-being

Screening women with PCOS for depression, anxiety, negative body image and eating disorders is important.

PCOS is a complex disease and should be managed by a team of medical practitioners from a dietitian, psychologist, gynaecologist, dermatologist and specialist physician. Team work can lead to a successful outcome.

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References

1. Azzizz R, Woods K et.al. (2004)’The prevalence and features of the polycystic ovary syndrome in an unselected population.’ J Clin Endocrinol Metab. 89,2745-2749
2. Dahlgren E, Janson P et.al. (1992) ‘Polycystic ovary syndrome and risk for myocardial infarction.’ Acta Obstet Gynecol Scand. 71,599-604
3. Diamanti -Kandarakis E, Dunaif A (2012) ‘Insulin resistance and the polycystic ovarian syndrome revisited: an update on mechanisms and implications.’ Endocr Rev, 33 981-1030
4. Hayek S.E., Bitar L et. al. (2015) ‘Polycystic ovarian syndrome: an updated overview’ Physiol, 7:124

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