Polycystic ovarian syndrome

PCOS is the commonest female endocrine problem seen in 5-7% of all women. It is characterised by ovarian dysfunction with the important features of hyperandrogensim and polyctic ovaries on pelvic ultrasound examination. It appears to have a familial tendency as 40 % of sisters and 20% of mothers of affected women also have the syndrome. It should be seen as a life long general medical condition rather than just a fertility issue.

It usually has peripubertal onset especially in girls with premature pubarche before the age of 8 years. A 'triggering insult' including obesity, insulin resistance, stress or dopaminergic dysregulation might be the unmasking factor. The main presentation at such a young age group would be acne, irregular periods and hirsutism. Unlike normal adolescent girls those with PCOS tend to have irregular menstruation even 3 years after menarche. Other skin problems tend to occur in older women including greasy skin, androgenic alopecia and dandruff. Pigmentation of the skin is seen less frequently with PCOS but mainly in association with insulin resistance. Such problems include velvety dark patches called acanthosis nigricans behind the neck, in the axillae and under the breasts as well as skin tags or flaps medically known as acrochordons. The more frequently seen problem of hirsutism is a distressing one for both young and older women. It entails growth of dark terminal hair in a male distribution pattern which is not socially acceptable. Different ethnic groups have different numbers of hair follicles per unit area of skin. Oriental women tend to have the least number compared to other races. Furthermore the perception of how much hair is unacceptable is different among different groups. However a score of more than 8 in the Ferriman-Gallwey scoring system is considered abnormal by most specialists. Hirsutism is generally related to exposure of the hair follicles to excessive androgens resulting in prolongation of the growth phase of the facial and body hair cycle. An opposite effect is seen on scalp hair follicles.

Women with PCOS are also prone to metabolic problems related to obesity, high blood pressure, insulin resistance and adult onset diabetes, abnormal lipid profile as well as gall bladder problems. Furthermore they are 30 times more likely to experience obstructive sleep apnoea syndrome (OSAS) in comparison to matched controls. It is not yet known whether this tendency is related to insulin resistance or hyperandrogenism but it could result in excessive daytime sleepiness. Though women with PCOS are thought to have increased risk of cardiovascular problems few epidemiological studies did not confirm this tendency.

A diagnosis of PCOS should also be considered in hyperandrogenic women with polycytic ovaries despite having regular menstruation. However other causes of hyperandrogenism should be excluded first. Furthermore a high level of LH is no longer considered necessary to confirm the diagnosis. It could be elevated in up to 60% of patients but its level could be affected by recent ovulation, ingestion of certain medication and BMI being higher in leaner patients. Furthermore it is secreted in 90- minute pusles and the level could depend on the timing of the sample within a pusle. As well pregnancy rate after induction of ovulation with clomid or gonadotrophins is not affected by LH level. On the other hand it has a prognostic value for treatment selection as patients with high LH level tend to have a better response after ovarian drilling. The reproductive side could also be tinted with increased risk of anovulation, irregular menstruation, heavy periods, repeated miscarriages, ovarian hyperstimulation syndrome and cancer of the endometrium. All these problems and risks come under interlinked Endocrine, Metabolic and Reproductive subgroups. Accordingly, regular specialist supervision is indicated to prevent many of these problems. Related medical problems could be controlled but not totally cured in most patients.