All You Need to Know About Polycystic Ovarian Syndrome (PCOS)

Medically reviewed by Dr. Ene Tolulope

WHAT IS PCOS?

You may have heard the term Polycystic Ovarian Syndrome (PCOS) before and may wonder why this disease is getting popular among women of childbearing age in recent times, includimg in Nigeria.

In this article, we explore all you need to know about Polycystic Ovarian Syndrome (PCOS).

Polycystic Ovarian Syndrome, shortened as PCOS, is a gynaecological condition affecting the endocrine (hormonal) system of some women in the reproductive age group. 

Historically, Stein and Leventhal in 1935, described a syndrome of hirsutism and amenorrhea (the absence of menstruations or one or more missed menstrual periods) in the presence of polycystic ovaries.

The term, “Polycystic ovary” implies the presence of multiple cysts in the ovaries.

This syndrome was previously called Stein-Leventhal syndrome. Further research on this disease with advances in medicine led to its present nomenclature – Polycystic Ovarian Syndrome (PCOS).

However, it is important to note that not every woman presenting with the features of this disease has the characteristic cystic appearance of the ovaries. 

In PCOS, women manifest with disturbances of the menstrual cycle, anovulation (absence of ovulation) and features of excessive male hormones (androgens) including acne, male pattern of hair distribution (hirsutism), amongst others.

HOW COMMON IS PCOS?

Statistics show that Polycystic Ovarian Syndrome, PCOS remains one of the commonest endocrine diseases affecting women between the ages of 18 -45. Surprisingly, with its rampant occurrence, very little awareness is made towards PCOS especially in Africa.

PCOS has a prevalence ranging from 22 to 26% of women, depending on the diagnostic criteria used to define the condition. A recent study in Nigeria reported its prevalence in 16.9-27.6% of women (depending on the diagnostic criteria used).

Interestingly, it is also not uncommon to find women with unrecognized cases of this syndrome. This is in the sense that some women suffering from PCOS may show no symptoms of the syndrome.

WHAT CAUSES PCOS?

The exact cause of Polycystic Ovarian Syndrome is unknown as researchers cannot pinpoint what leads to the development of abnormal cysts in the ovaries.

Nevertheless, studies have shown that a number of factors put people at higher risk of developing PCOS. These include an interplay of genetic and environmental influences. 

Over secretion of Androgens

Excess production of androgens by the ovaries is stimulated by an imbalance in gonadotropins levels, specifically the Luteinizing hormone (LH), leading to incomplete development of multiple immature ovarian follicles. The immature follicles give the ovaries the classical ‘cystic’ appearance characteristic of polycystic ovaries. 

Genes

Studies have equally shown that PCOS runs in families. This means a girl-child is likely to develop PCOS if a member of the family has the condition. Hence, heredity influences the tendency of a women ton develop PCOS. This is why a part of the clinical investigation for PCOS diagnosis is patient history.

Insulin resistance

Research has it that up to 70% of women who suffer PCOS also have insulin resistance. Insulin resistance means that their cells are unable to utilize the insulin hormone properly.

The insulin hormone is a hormone produced by the pancreas cells, which helps the body utilize the glucose (sugar) metabolized from food. Without insulin hormone, the cells would be unable to use glucose properly, leading to a high blood sugar (glucose) level.

When the body cells cannot properly utilize insulin hormone, the body’s demand for the hormone increases. In response to this high demand, the pancreas ends up producing more insulin.

However, this tends to do more harm than good to the females in the sense that the increase in insulin levels almost always triggers the ovaries to make more male hormones. The excessive male hormone is what causes some symptoms of PCOS, such as hirsutism and acne.

Note: One of the common risk factors of insulin resistance is obesity. Obesity and insulin resistance have both been linked to Type 2 diabetes and are thus risk factors of diabetes.

Inflammation

Women who have PCOS also experience high levels of inflammatory reactions in their body. Again, obesity has been linked to inflammation. Notice the link between being overweight and suffering PCOS. Research has linked increased inflammation to an excess level of androgen hormone in the body. 

Even though physicians cannot tell exactly what causes Polycystic Ovarian Syndrome, thorough studies on the subject have given credence that the factors mentioned above contribute greatly to the development of PCOS.

WHAT ARE THE SYMPTOMS OF PCOS?

Clinical features of PCOS are varied and may include majorly abnormalities of the menstrual cycle (oligomenorrhea, amenorrhea), anovulation, and features of hyperandrogenism (hirsutism, acne). Other features seen in women with PCOS include infertility, obesity and glucose intolerance manifesting with symptoms and signs of Diabetes Mellitus.

HOW IS PCOS DIAGNOSED?

The diagnosis of PCOS is mainly clinical. A good clinical history and physical examination would usually give pointers to the condition. Biochemical investigations, ultrasonographical features and laparoscopic findings may also help with this diagnosis. 

Various bodies have proposed several diagnostic criteria. One of the universally accepted one is called the Rotterdam criteria, described by the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM).

A diagnosis of PCOS is made in the presence of two of the following three criteria:

• Oligo-ovulation or anovulation manifested as oligomenorrhea or amenorrhea
• Hyperandrogenism (clinical evidence of androgen excess) or
• Hyperandrogenemia (biochemical evidence of androgen excess)

Biochemical investigations in PCOS include serum gonadotropin levels, with an elevated Luteinizing Hormone (LH) level being significant.

Typically, the Follicle-stimulating hormone (FSH) to Luteinizing hormone (LH) ratio on the third day of the menstrual cycle is high, above 2:1 or 3:1. Androgen levels (testosterone, androstenedione) are also typically elevated in women with PCOS.

Blood glucose levels may be elevated as well. Ultrasonographic features of PCOS include the presence of immature follicles which are seen as multiple (usually over 12) small follicles 5-7mm in diameter, arranged around the periphery of the ovaries in a ‘string-of-pearls’ pattern. 

HOW IS PCOS MANAGED?

The goals of therapy in managing PCOS depend on the presentation in the individual woman. Management of this condition involves non-pharmacological, pharmacological and surgical methods. Non-pharmacological measures include weight reduction through dietary modification and exercise. Drug therapy aims to control insulin resistance, stimulate withdrawal bleeding, and suppress androgen production, improving fertility by stimulating ovulation.

Furthermore, ovulation can be stimulated using clomiphene citrate tablets. Oral contraceptive pills, preferably combined oral contraceptives (containing Ethinyl, estradiol and progestin) can effectively suppress the hypothalamic-pituitary-gonadal axis.

Metformin tablets are used to improve insulin sensitivity and control glucose intolerance. Other treatment may be tailored to the specific needs of the individual. Surgical treatment options include laparoscopic ovarian drilling, electrocautery and multiple biopsies, all aimed at improving fertility. 

WHAT OTHER CONDITIONS MAY PRESENT SIMILAR TO PCOS?

Some other medical conditions may cause clinical features that may mimic PCOS. It is important to note these and exclude them when making a diagnosis of PCOS. These differential diagnoses include the following: Hyperprolactinemia, Cushing’s syndrome, Hypothyroidism, Congenital adrenal hyperplasia and Androgen-secreting tumours.

HOW DOES PCOS AFFECT A WOMAN’S BODY?

Health challenges

As a woman, having excess male hormone in your body can affect certain aspects of your health, such as fertility and mental health. PCOS increases the risk for infertility, miscarriages, endometrial hyperplasia, cardiovascular diseases including hypertension, dyslipidemia and stroke, type 2 Diabetes mellitus, anxiety disorders and depression.

Infertility

A woman cannot get pregnant when without ovulation. Also, if you don’t ovulate regularly, it means you don’t release as many eggs (monthly) that would be needed for fertilization to occur. Anovulation (absence of ovulation) is one of the PCOS symptoms, which is one of the leading causes of infertility in women.

Endometrial cancer

Ovulating every month causes the endometrial lining (a membrane that covers the surface of the uterus) to be shed every month. The endometrial lining is actually what is shed every month as menstrual blood. However, when you don’t ovulate regularly, there can be a build-up of the endometrial lining. A thickened endometrium (endometrial hyperplasia) increases the risk for endometrial cancer.

Anxiety and depression.

Women with Polycystic Ovarian Syndrome experience different symptoms which can affect their mental health negatively and cause disorders like depression and anxiety. This is because the fluctuation in hormone levels can affect the woman’s mood and can trigger a state of depression. Other symptoms like acne and unwanted excessive hair growth can affect emotions and cause sadness, low self-esteem and anxiety.

Irregular Periods

AS earlier stated, PCOS is a disease of the ovary. The condition of the ovaries happens to be a very important factor in menstruation. Thus, as these immature follicles are spread out in the ovaries, they can most likely cause anovulation which is an inability to ovulate properly. Once the process of ovulation is affected, the menstrual cycle is impacted.

Read more on Irregular Periods: Causes and Home Remedies to Regulate your Cycle.

Metabolic disorders

A greater percentage of women with PCOS are obese or overweight. Both polycystic ovarian syndrome and obesity have been linked to a range of metabolic issues which include high blood pressure, high blood sugar, high level of low-density lipoprotein (bad cholesterol) and low level of high-density lipoprotein (good cholesterol). These metabolic issues are collectively called metabolic disorders and can predispose one to other health conditions such as diabetes, heart diseases and stroke. 

Sleep apnoea

Sleep apnoea is a condition in which someone pauses in between breaths while sleeping. Sleep apnoea can be a serious issue and can interrupt sleep. Some of its symptoms include gasping for air while sleeping, loud snoring, difficulty staying awake and waking up with a headache. Sleep apnoea is common in women who have PCOS and are obese as well. A study showed that the risk for sleep apnoea is 5-10 times higher in obese women who have PCOS than those without PCOS. 

PCOS AND PREGNANCY

When it comes to pregnancy, there is a lot to learn about Polycystic ovarian syndrome. PCOS affects the normal menstrual cycle, causes amenorrhea and even makes it harder to get pregnant. Many women with PCOS have fertility issues.

However, this doesn’t mean a woman with the polycystic ovarian syndrome can’t get pregnant. With proper Consultation with an Expert, dietary and lifestyle changes, a successful pregnancy can be attained. 

One thing you also need to know about the polycystic ovarian syndrome is that even when pregnancy has been attained, the condition still increases the risk for certain pregnancy symptoms.

For instance, pregnant women with PCOS have a higher risk of giving birth to premature babies. They are also at a higher risk of developing gestational diabetes, high blood pressure and miscarriage. 

TIPS TO HELP MANAGE PCOS 

Dietary changes and weight loss

The good news is that Polycystic Ovarian Syndrome is not life-threatening per se, but if not managed, it can lead to other health conditions which can be life-threatening. Most of the workable PCOS treatments usually focus on dietary changes and weight loss.

Many women with PCOS also suffer from obesity. However, studies have shown that losing excess weight can help regulate menstruation and improve other PCOS symptoms.

When you start losing weight, you are also on the right path to improving your blood cholesterol levels, reducing heart diseases, diabetes risks, and blood insulin levels. Some studies have confirmed that going on low-carb diets like the ketogenic diet and eating foods with low-glycaemic index can help regulate the menstrual cycle.

Exercise

Exercise is also highly recommended to help treat and manage your PCOS symptoms. When exercise is added to one’s weight loss regimen, ovulation is enhanced and the insulin levels is improved.

Thus, women with PCOS should consider participating in about 30 minutes of moderate-intensity exercise, three times a week in order to manage their condition.

When combined with a healthy dietary lifestyle, exercise offers a more effective solution to PCOS symptoms. Practicing these two improves weight loss, enhances menstruation, ovulation and insulin levels, and reduces the risk of developing heart diseases and diabetes. 

WHEN SHOULD YOU SEE A DOCTOR?

Do you experience symptoms similar to those listed of PCOS? What are the signs and symptoms that should make you suspect PCOS, and when do you see your doctor?

Consult a Doctor if:

• you experience irregular menstrual cycles
• you experience diabetes symptoms like unexplained changes in weight, blurred vision and excessive thirst or hunger
• you have been trying to get pregnant for more than one year but have been unable to

CONCLUSION

The polycystic ovarian syndrome is a common disease affecting women, causing various clinical features including anovulation, hirsutism and menstrual disturbances. It can be managed using a variety of treatment modalities tailored to the individual’s specific presentation. 

If you have been diagnosed with PCOS, regular visits to your doctor will help manage your condition and help check for other possible complications from PCOS such as high blood pressure and diabetes. If you experience symptoms of PCOS as discussed in the article, it would help to Book an Appointment with a doctor today so as to get a prompt diagnosis.

REFERENCES

American College of Obstetrics and Gynaecology. Polycystic Ovary Syndrome.  Clinical Updates in Women’s Health Care. 2016. Available from:

Maharaj S, Amod A. Polycystic ovary syndrome. Journal of Endocrinology, Metabolism and Diabetes of South Africa. 2009 Jul 1;14(2):86-95.

Schroeder BM. ACOG releases guidelines on diagnosis and management of polycystic ovary syndrome. American family physician. 2003 Apr 1;67(7):1619.

Wolf WM, Wattick RA, Kinkade ON, Olfert MD. Geographical prevalence of polycystic ovary syndrome as determined by region and race/ethnicity. International journal of environmental research and public health. 2018 Nov;15(11):2589.

ABOUT THE CO-AUTHOR

Dr. Ene Tolulope Keshy is a Senior Resident doctor in Family Medicine at the National Hospital Abuja Nigeria. She is passionate about health and healthy living.  In her spare time, Dr. Keshy loves to read, write and enjoy nature.