Polycystic Ovarian Disease

It is estimated that 10% of women in the reproductive age have Polycystic Ovarian Disease (PCOS for short). They usually have high level of androgens, which are male hormones, and have an irregular or don't have menstrual cycle at all.

Other symptoms of PCOS are:

Here is an article that explains PCOS in a much more depth:

Polycystic Ovary Syndrome (PCOS)

The endocrine disorders among females are of various types but the most common one is the polycystic ovary syndrome (PCOS) which is basically an inherited disorder and can be received from either parent. The chances of occurrence of this disorder vary from 5-10% among the females of age group of 12-45 resulting in female sub-fertility. This endocrine disorder can be identified by anovulation which is diagnosed by irregular menstruation, amenorrhea, polycystic ovaries, ovulation-related infertility, excessive secretion of androgenic hormones that cause hirsutism and acne. High cholesterol level, type 2 diabetes, insulin resistance are other known symptoms. All these symptoms vary among different individuals. The disorder is known by a number of other names like polycystic ovary disease, functional ovarian hyperandrogenism, ovarian hyperthecosis and Stein-Leventhal syndrome. A polycystic ovary has abnormal number of eggs that can be viewed near its surface resembling cysts.

The Definition of Polycystic Ovary Syndrome

Polycystic ovary syndrome is generally described by two definitions. First definition was given by NIH or NICHD in 1990 which suggests that if a female is suffering from oligoovulation, shows signs of androgen excess and other entities that result in polycystic ovaries then the female is suffering from this endocrine disorder.

The second definition was given in a workshop sponsored by ESHRE/ASRM held in Rotterdam in 2003 which predicts that if a female is suffering from oligoovulation or anovulation, has excess androgen activity and symptoms of polycystic ovary then she is suffering from polycystic ovary disease. The second definition appears to be wider and acceptable.

The chief symptoms of the polycystic ovary syndrome include menstrual disorders chiefly amenorrhea and oligomenorrhea but other menstrual disorders may also crop up. Chronic anovulation results in infertility. High levels of androgens result in acne and hirsutism. Hypermenorrhea and other symptoms can also make their appearance. About three quarters of the females suffering from this endocrine disorder generally suffer from hyperandrogenemia. Central obesity and insulin resistance are also noticed. Serum insulin and homocysteine levels are significantly higher in females with this disease.

The PCOS and the Follicles

It is not always necessary that the women suffering from polycystic ovary syndrome (PCOS) may have polycystic ovaries and similar is the condition that all the women with polycystic ovaries may not suffer from this syndrome. The syndrome can be easily diagnosed by the pelvic ultrasound but other diagnostic tools are also available. History of the individual based on menstrual pattern, obesity, hirsutism and absence of breast development can help the medical professional.

Gynecologic ultrasonography can be performed which helps in the detection of small ovarian follicles. These small follicles are believed to be formed due to disturbed ovarian function where ovulation has failed to take place due to absence of menstruation. In a normal menstrual cycle a single egg is released from the dominant follicle. After ovulation, the remnant of the follicle is converted into a characteristic structure known as corpus luteum formed by the action of progesterone. This structure finally disappears after 12-14 days.

In polycystic ovary syndrome, although a number of follicles are formed but none of them grows more than 5-7 mm in length and fail to enter the preovulatory stage of the menstrual cycle. According to the Rotterdam criteria there must be 12 or more than 12 small follicles detected in the ultrasound. These small follicles are generally present near the periphery of the ovarian wall giving it the appearance of string of pearls. The ovary enlarges and attains a size which is 1.5 to 3 times greater than the normal size and this is due to the presence of these abnormal follicles.

Laparoscopic Examinations and the Polycystic Ovary Syndrome

Laparoscopic examinations depict the presence of a white, smooth outer surface of ovary. The serum (blood) levels of androgens specifically androstenedione and testosterone are elevated. The levels of dehydroepiandrosterone sulphate are also higher. The free testosterone levels are also high and it gives the best clue about the presence of this syndrome. The free androgen index of the ratio of testosterone to sex hormone binding globulin (SHBG) is generally higher but it is a poor indicator. Some blood tests are also suggested but they are not good indicators of the diagnosis of the polycystic ovary syndrome. The ratio of LH (Luteinizing Hormone) to FSH (Follicle Stimulating Hormone) is greater than 1:1 as tested on the third day of menstruation.

Among the obese women the levels of the sex hormone binding globulin (SHBG) is generally low. Fasting biochemical screening and lipid profiling of the individual can be carried out while searching for this syndrome. A 2-hour oral glucose tolerance test (GTT) of the suspected individuals can be carried out which indicates impaired glucose tolerance in 15-30% patients of this syndrome. Insulin resistance is very commonly noticed in the patients of polycystic ovary syndrome. Other clinical disorders may also be associated with menstrual abnormalities namely Cushing's syndrome, hypothyroidism, congenital adrenal hyperplasia and pituitary disorders.

Polycystic Ovary Syndrome (PCOS) and the Inheritance

Polycystic ovary syndrome (PCOS) is a generically inherited condition. It is inherited in an autosomal dominant system with higher risk of occurrence in females. The chances of inheriting the gene responsible for this syndrome are 50% if the parent is carrying the gene. The gene responsible for this syndrome can although be inherited either from the father or the mother and the gene can be passed to the sons but the symptoms may arise only in the daughters. The gene responsible for this disorder has not been yet identified.

Polycystic ovaries generally develop when the ovaries are stimulated to produce excessive amounts of the male hormones particularly testosterone. This may happen due to release of excessive amounts of the luteinizing hormone (LH) from the anterior pituitary gland or elevated levels of insulin in the blood of women who are sensitive to insulin or reduced levels of sex hormone binding globulin (SHBG) in blood which results in increased level of free androgens. The syndrome has acquired its name polycystic due to resemblance of the small follicles with the cysts. The follicles develop from the primordial follicles but their development ceases at the antral stage due to the disturbed ovarian function. These cysts like follicles get arranged at the periphery of the ovarian wall. Majority of the patients with this disorder in general show insulin resistance and this can cause abnormalities similar to those observed in the hypothalamic-pituitary-ovarian-axis.

The Symptoms of the Polycystic Ovarian Disease

The symptoms of the polycystic ovarian disease are very complex and may not be same for all the patients. In many cases it can be characterized by hyperandrogenism and insulin resistance. Majority of the cases of this disease have a genetic basis. The excessive amounts of the adipose tissue in the obese individuals also increase levels of androgens and estrogens. Adipose tissue carries an enzyme identified as aromatase that participates in the conversion of androstenedione to estrone and testosterone to estradiol. Hyperinsulinemia causes an increase in the GnRH pulse frequency, increased ovarian androgen production, decreased follicular maturation and decreased sex hormone binding globulin levels that ultimately result in polycystic ovary disease.

Chronic inflammations may also result in this syndrome. A study carried out in the United Kingdom indicated that the incidence of polycystic ovary disease is higher in the lesbian women than the heterosexuals. The medications given to the patients of this disease generally focus on lowering of insulin levels, fertility restoration, hirsutism or acne treatment and prevention of endometrial hyperplasia, endometrial cancer and restoration of regular menstrual cycle. Cases where the disease is associated with obesity, weight loss is the effective strategy for the commencement of regular menstruation. Low carbohydrate diet and regular exercise may help in weight loss.

The Polycystic Ovarian Disease and the Anovulation

All the females with the polycystic ovary disease may not face the difficulty of becoming pregnant only those suffering from anovulation may face the problem. Patients with the problem of anovulation may be treated with clomiphene citrate and FSH injections. The patients who fail to give positive results with clomiphene and FSH treatments are treated with assisted reproductive technology procedures like controlled ovarian hyperstimulation with follicle stimulating hormone (FSH) injections followed by in vitro fertilization (IVF). Surgery is generally not performed in case of the polycystic ovary but a laparoscopic procedure known as ovarian drilling is generally carried out. Hirsutism can be treated by using an effective standard contraceptive pill.

The key ingredient of the contraceptive pills is cyproterone acetate which is a progestogen. This compound is anti-androgenic in action and blocks the activity of male hormones that are responsible for acne and unwanted hair growth on face and over body. Other drugs that carry anti-androgen effects include flutamide and spironolactone that can effectively reduce hirsutism. Spironolactone is the most commonly used drug in the United States. Menstrual problems can be regulated by the use of contraceptive pills but these drugs can cause additional problems if continued for a long time. Two inositol isomers namely D-chiro-inositol and myo-inositol have given promising results against this syndrome.

The Risks of Suffering the Polycystic Ovary Syndrome

Women suffering from polycystic ovary syndrome are at the risk of getting affected with endometrial hyperplasia and endometrial cancer. These clinical manifestations may crop up due to over accumulation of the uterine lining and absence of progesterone which is responsible for the prolonged stimulation of the uterine cells by estrogen. These symptoms set a positive background for the appearance of other health problems like obesity, hyperinsulinemia, hyperandrogenism, type-2 diabetes and insulin resistance.

A study conducted in 2010 spotlighted that the women suffering from polycystic ovary disease are at an elevated risk of getting affected with type-2 diabetes and insulin resistance. High blood pressure, depression or depression with anxiety, miscarriage, excessive weight gain, cardiovascular disease, acanthosis nigricans, autoimmune thyroiditis are other risks associated with this syndrome.

Navodita Maurice

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