Polycystic Ovarian Syndrome (PCOS)
Also known as Stein-Leventhal syndrome

PCOS is a common problem which affects many young women (30%). Of these only a small minority will have PCO disease which affects about 3% of the female population of childbearing age.

PCOS is also known as hyperandrogenic chronic anovulation. It may manifest itself in many different ways but is characterized by irregular ovulation and menses, obesity, insulin resistance, acne, and excessive hair growth. In addition, vaginal ultrasound of the pelvis shows large ovaries with multiple cysts round their outer edge and a dense core.

Between 5 and 30% of women have some characteristic of PCOS making it the most common hormonal abnormality in women of reproductive age.

It is not clear exactly what causes PCO as there are a number of different presentations but in all women the normal hormone cycle is disrupted. There are several theories as to why this might occur.

1. Increased LH production by the pituitary gland. This raises testosterone like hormones which interfere with proper ovulation. Causing cysts on the ovary.

2. Increase insulin resistance. Which makes it more difficult for cells to take up sugar. As a result more insulin is produced leading to hyperinsulinemia. In PCOS, this hyperinsulinemia leads a fall in sex hormone binding globulin and to an increase in free testosterone production. This interferes with ovulation and causes acne and male pattern hair distribution.

What exactly causes these two things to happen remains unclear. Obeisity may play a major role due to its’ effect on insulin resistance and thus hormone levels, but not all women with PCO are overweight.

Symptoms

The common symptoms of PCOS are listed below. Few women will have all of these symptoms:

· Weight gain
· Irregular or absent periods
· Acne
· Male-pattern balding
· Hirsutism (excessive hair growth)
· Lack of ovulation and thus infertility
· Multiple small ovarian cysts-on ultrasound examination
· Insulin resistance leading to diet and drug controlled, type II diabetes
In addition to causing these unpleasant symptoms and signs, PCOS is a significant risk factor for Type II diabetes (non-insulin dependent), heart disease, elevated cholesterol (hypercholesterolemia) and possibly endometrial cancer. Proper long term management is therefore essential.


Treatment

There are a number of available treatment options. The treatment given will depend on the presenting complaint and the desire for pregnancy.

1. Weight Loss –This is the most important of all treatments and the most difficult to achieve. Improved diet and exercise decrease insulin resistance and insulin levels, which may reverse the hormonal imbalance and allow ovulation and periods to return.

2. Progestins -These medications mimic the action of progesterone (Norethisterone and medroxy progesterone acetate). Progestins may be used to regulate the menstrual cycle and reduce blood levels of LH. Unfortunately, they are of little benefit in reducing hair growth or metabolic abnormalities and have side effects. In addition they are effective contraceptives.

3. Oral Contraceptives -The combined "pill" is an effective treatment for PCOS in patients not wanting to become pregnant. Normal ovarian function is reduced lowering androgen production and LH levels. The pill may also be used to decrease symptoms such as male pattern hair distribution associated with high androgen levels (acne and hirsutism). The ideal pill to use in this context is Dianette which had cyproterone acetate, an anti testosterone drug in it.

4. Anti-Androgens -These can only be used in women using adequate contraception because these medications pose a risk to the developing fetus. The value for use in PCOS is to improve skin conditions and to decrease other symptoms such as male-pattern baldness and hirsutism. Examples include cyproterone acetate and spironolactone.

5. Fertility drugs -In PCOS, normal follicular growth and ovulation are disrupted. Fertility drugs may be used in order to induce ovulation. Clomiphene citrate is typically the first agent prescribed to stimulate ovulation. If clomiphene is unsuccessful, more potent medications may be indicated together with artificial insemination.

6. Surgical therapy -2 surgical therapies are available:

Ovarian wedge resection where part of the ovary is removed and then the remaining ovary issewn back together. This procedure has been effective in decreasing LH and androgen production, and reestablishing regular menses in over 75% of patients. Pregnancy rates following ovarian wedge resection vary, but have been reported to be as high as 60%. Unfortunately, a major complication of this procedure is the formation of pelvic adhesions in 30% of patients.
The more popular option is to perform laparoscopic ovarian drilling
This procedure involves destroying part of the ovary by drilling it with a laser, diathermy or Helica. Ovarian drilling can be performed during the time of a laparoscopy and may be very effective in reducing androgenic hormone production. Laparoscopic ovarian drilling may be an effective treatment in clomiphene-resistant anovulatory women with PCOS.


Alternative treatment for PCOS

Treating the insulin resistance associated with PCOS targets the cause rather than the symptoms of the disorder. Approximately 75% of obese patients with PCOS are insulin resistant and have elevated amounts of insulin in their bloodstream. These women are relatively insulin resistant and may be helped by taking drugs that increase peripheral insulin sensitivity and glucose uptake and therefore, helps to normalize the hormonal abnormalities associated with PCOS. The most commonly used of these is Metformin:


Metformin

Metformin is mainly used in non-insulin dependent diabetes and helps enhance the body's sensitivity to insulin. It does not cause hypoglycemia (low blood sugar) which is important to prevent unwanted side effects. Some patients have experienced weight loss, improved lipid profiles, lowered blood pressure, return of menstruation, and achieved pregnancy while taking metformin. There is increasing evidence that this drugs is of use to all women with PCO, not just those women who are obese. It is becoming widely used particularly as it does not have some of the problems associated with ovulation induction agents. This drug is considered relatively safe. The most frequently occurring side effect is diarrhoea.

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