PCOS

Overview

Polycystic ovarian syndrome (PCOS) is a heterogenous disorder characterized by androgen excess, ovarian dysfunction and polycystic ovaries.

Causes

Not clearly known.

Changes in lifestyle, diet and stress may lead to it.
Genetic factors e.g CYP 21 gene mutation may play a role.
Family history of PCOS or diabetes.

Symptoms

Absence of periods or delayed cycles
Irregular cycles.
Infertility
Hirsuitism i.e increased hair growth over face and body.
Acne
Obesity
Alopecia

In adults cycles interval of >45 days, <8 cycles per year needs evaluation for PCOS. In adolescents 1 year post menarche delayed cycle for >90 days needs evaluation.

PCOS is also associated with various other disorders such as Diabetes, Cardiovascular diseases and Metabolic syndrome.

How is it diagnosed?

Based on Rotterdam criteria, where two of the following should be present,

Oligo or anovulation characterized by delayed cycles or absence of menses.
Clinical or biochemical evidence of hyperandrogenism i.e acne, hirsuitism or alopecia or lab evidence.
Ultrasound criteria: To be used only in adults. Using VS a follicle number of ≥20 per ovary, and/or ovarian volume of ≥10ml of either ovary.

Investigation

Calculated free testosterone or free androgen index is assessed.
Thyroid profile and other hormones are evaluated according to symptoms.
Lipid profile
Screening for diabetes is also done. 75 gm oral Glucose tolerance test is done.
Ultrasonography: Transvaginal ultrasound is preferred if patient is sexually active. Ultrasound not a reliable criteria for diagnosis in adolescents.

Management

Lifestyle Modification: Includes Dietary advice and Regular physical activity.
Dietary advice: 1200 -1500 Kcal diet is recommended. 30 % calorie deficit diet is advised to patients with excess weight.
Patients are recommended to cut down on refined sugar, refined oil and simple carbs. Intake of complex carbohydrates, seasonal fruits and vegetable is advised.
Regular Physical Activity: 30-45 mins of moderate physical activity is recommended at least 5 times a week in adults.
60 mins of moderate physical activity is recommended in adolescents.
Those who keep an account of steps, 10000 steps per day is adequate to maintain it.
Adequate water intake: 3 liters per day.
Other lifestyle changes: Follow a schedule. Early to bed and early to rise rule should be followed.
Yoga, Meditation helps to keep stress levels down.

Treatment

Drug Therapy
Combined oral contraceptives: Low dose OCP is the first treatment option for patients with PCOS.

OCPs with antiandrogen like cyproterone is preferred for cases with hirsuitism or biochemical evidence of hyperandrogenism.

Insulin Sensitizers: Metformin is indicated in cases with impaired glucose tolerance, high BMI, acanthosis nigricans (dark patches on folds of skin like neck).
Antiandrogens: For hirsuitism.

Newer therapies: Myoinositol derivatives

Surgical Management:
Laproscopic ovarian drilling: Can improve fertility rates.