Polycystic Ovary Syndrome (PCOS)
It took me a while to decide on what to write as it is quite a complex syndrome but yet a common one. Studies have shown that PCOS is very common affecting approximately 20 in 100 of women –> 20% of women!
What is PCOS?
It is a complex endocrine condition which can affect a woman’s appearance, menstrual cycle, fertility, hormone levels and cardiovascular system. PCOS can also have detrimental effects on long-term health.
What causes PCOS?
The cause of PCOS is unknown and is likely to be multi-factorial. There is evidence that it is a genetically linked condition which means if any of your relatives have PCOS, it increases your risk of developing PCOS.
Symptoms of PCOS:
Symptoms associated with PCOS are linked to abnormal hormone levels and the severity and range of symptoms may vary from woman to woman. In PCOS, women have higher levels of testosterone and higher levels of insulin which can give rise to symptoms of:
– Infrequent, absent or irregular menstrual periods
– Reduced fertility * In fact, PCOS, is the most common cause of female subfertility
– More facial or body hair than usual
– Acne, oily skin
– Depression and mood swings
– Weight gain, obesity
Diagnosis of PCOS:
It is often challenging to diagnose PCOS and often it may take a while to get a diagnosis of PCOS as women who have PCOS have different signs and symptoms which may come and go and can also be contributed to other lifestyle stressors.
To diagnose PCOS, you usually will need to have two of the following criteria present, as long as other causes of menstrual disturbances and hyperandrogenism (eg: thyroid dysfunction,etc) are excluded:
1) Irregular period, infrequent periods or no periods
2) More facial or body hair than what is usual for yourself +/- higher blood testosterone levels
3) Ultrasound scan which shows polycystic ovaries.
*Polycystic ovaries are very common and affects up to 20% of women. However, only approximately 7% of women with polycystic ovaries have PCOS.
Subfertility and PCOS:
More often than not, the diagnosis of PCOS arises when there is difficulty in getting pregnant leading on to subfertility. PCOS is the most common cause of female subfertility.
Before any intervention is initiated for women with PCOS, preconception counselling should be provided emphasizing on the importance of life style – weight reduction and exercise in overweight women, reduction in smoking and alcohol consumption.
Usually, the reason for subfertility in women with PCOS is due to the lack of ovulation.
Current recommended 1st line treatment for ovulation induction remains the usage of clomiphene and patients should be informed that there is an increased risk of multiple pregnancies with ovulation induction using clomiphene. (Grade A, Level 1+ evidence)
Recommended 2nd line intervention for subfertility in women with PCOS is either exogenous gonadotrophins or laparoscopic ovarian surgery. (Grade D, Level 4 evidence)
Recommended 3rd line intervention for subfertility in women with PCOS is in vitro fertilization (IVF). (Grade C, Level 2+ evidence)
The routine use of metformin in ovulation induction is not recommended as monotherapy or in combination with clomiphene. (Grade D, Level 3). On the other hand, the combined use of metformin and clomiphene is recommended for women with clomiphene resistance especially if they are obese (BMI > 27.5). (Grade A, Level 1+)
In women who have been diagnosed with PCOS prior to pregnancy, especially those requiring ovulation inductions for conception, they should be screened for gestational diabetes before 20 weeks of gestation, with referral to a specialist obstetric diabetic service if abnormalities are detected. (Grade B, Level 1+)
PCOS and subfertility is a daunting prospect but it need not be. With the aid of your doctor/specialist the problems associated with PCOS can be addressed and hopefully resolved. Liaising with your doctor will provide great strides towards overcoming subfertility and achieving pregnancy.
Long term health issues associated with PCOS:
· Insulin resistance and diabetes (10-20% of women with PCOS go on to develop diabetes)
· High blood pressure (hypertension)
· Heart disease (likely linked to other health conditions – diabetes, hypertension)
· Endometrial (lining of the uterus) cancer
· Mood swings and depression
· Obstructive sleep apnoea
Patients presenting with PCOS, particularly if they are obese or have a strong family history of type 2 diabetes or > 40 years of age should be offered a glucose tolerance test (Grade B, Level 1+) to assess for diabetes. Patients with PCOS are advised to have regular check-ups and also have their cardiovascular risk factors stratified (including blood pressure, cholesterol, triglycerides and HDL cholesterol) and treated accordingly. (Grade B, Level 2++)
There is currently no cure for PCOS and the aim of medical treatment is to manage the symptoms and consequences of having PCOS.
A healthy lifestyle (weight loss, exercise and balanced diet) and regular health checks are important in the management of women with PCOS.
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