Polycystic ovary syndrome (PCOS) is a significant public health issue with reproductive, metabolic and psychological features. PCOS is one of the most common conditions in reproductive aged women. Women with PCOS present with features including psychological (anxiety, depression, body image) , reproductive (irregular menstrual cycles, hirsutism, infertility and pregnancy complications) and metabolic features (insulin resistance (IR), metabolic syndrome, prediabetes, type 2 diabetes (DM2) and cardiovascular risk factors.
Diagnosis and treatment of PCOS remain controversial with challenges defining individual components within the diagnostic criteria, significant clinical heterogeneity, ethnic differences and variation in clinical features across the life course.
According to the World Health Organization (WHO) estimation revealed over 116 million women (3.4%) are affected by PCOS worldwide. Its etiology remains unknown, and treatment is largely symptom based and empirical. This multifactorial condition initially develops in adolescents who are at high risk for the emergence of several comorbidities including obesity, type II diabetes, infertility, endometrial dysplasia, cardiovascular disorders, and psychotic disorders .
Clinical Presentation
Menstrual dysfunction occurs in 75% to 85% of patients
? Oligomenorrhea or amenorrhea (infrequent or absent menstrual bleeding) is the most common pattern, with most intervals longer than 35 days. (Having fewer than 8 periods a year).
? Onset is usually in adolescence; may start at menarche or shortly thereafter. .
? In some adolescents, condition is noted by absence of established regular menses.
? Ovulatory dysfunction can be present subclinically with no obvious disruption in regularity of vaginal bleeding. .
? 15% to 40% of women with hyperandrogenism and regular menses have ovulatory dysfunction.
History of infertility
? Common presenting issue; nearly 70% of patients report infertility.
Hair and skin concerns
? Growing thick, dark hair on the upper lip, chin, sideburn area, chest, or belly.
? Excessive terminal body hair growth is a common concern.
? Hirsutism develops gradually and worsens with weight gain.
? Acne can occur with hirsutism; overall, acne is less common as a presenting complaint (15%-30% of patients).
? During adolescence, acne is not considered a firm sign of hyperandrogenism; however, if it persists into the mid-20s or 30s, it is often a sign of hyperandrogenism.
? Hair loss, when it occurs, is most pronounced over vertex or crown and spares frontal hairline.
Overweight or obesity
? Central distribution of adiposity also may be present in those with BMI in reference range.
? Overweight: BMI of 25 kg/m² or higher.
? Obese: BMI of 28 kg/m² or higher.
? Waist circumference greater than 88 cm is considered abdominal obesity in women.
? Waist to hip ratio greater than 0.8 is considered unhealthy.
What causes PCOS?
Polycystic ovary syndrome is a multifactorial disorder arising from the interaction of abnormal genetic, metabolic, endocrine, and environmental factors all contributing to disease. In PCOS, the ovaries do not work normally and there is hormonal imbalance.In people with PCOS, the ovary makes many small follicles instead of a big one. And ovulation doesn't happen every month the way it is supposed to.
Diagnosis
?Polycystic ovary syndrome is a diagnosis of exclusion
• Common disorders that should be excluded include:Thyroid disease (hypothyroidism or hyperthyroidism), Hyperprolactinemia and Nonclassic congenital adrenal hyperplasia.
• When considering diagnosis, obtain laboratory tests to exclude other common conditions (this exclusion is required to assign diagnosis), such as:
?Serum TSH level to screen for thyroid dysfunction.
• Serum prolactin level to test for hyperprolactinemia.
• 17-hydroxyprogesterone level (obtained before 8 AM) to test for congenital adrenal hyperplasia.
• Consider this diagnosis in any reproductive-aged woman.
• Diagnostic criteria (Rotterdam criteria ) in adults require that at least 2 of the following 3 conditions be met:
?Clinical or biochemical hyperandrogenism.
? Clinical hyperandrogenism may include hirsutism, acne, or androgenic alopecia
? Biochemical hyperandrogenemia is determined by elevated serum androgen level.
? About 25% of patients do not exhibit clinical features of hyperandrogenism but have biochemical evidence of hyperandrogenemia
Diagnosis in an adolescent requires special considerations
Diagnosis in adolescents is controversial because it is complicated by several factors.
? Many features of polycystic ovary syndrome (including acne, menstrual irregularities, and hyperinsulinemia) are common in normal puberty.
? Menstrual irregularities with anovulatory cycles and varied cycle length are common in adolescents for approximately 2 years after menarche owing to immaturity of hypothalamic-pituitary-ovarian axis.
? Multicystic ovaries are a common normal finding in adolescents owing to natural ovarian development at menarche.
Proposed criteria for diagnosis in adolescents include the otherwise unexplained combination of:
? Abnormal uterine bleeding pattern that meets both of the following requirements:
? Abnormal for gynecologic age (eg, ovulatory dysfunction that persists more than 2 years after menarche) .
? Cycles shorter than 19 days or longer than 90 days are abnormal at any stage .
? 75% of menstrual cycles range from 21 to 45 days duringfirst postmenarchal (gynecologic) year.
? 95% of adolescents achieve 21- to 40-day adult menstrual cyclicity by fifth gynecologic year.
? Persistent symptoms for 1 to 2 years.
Unequivocal evidence of hyperandrogenism, including at least 1 of the following:
? Persistent testosterone elevation above adult reference range, obtained from a reliable reference laboratory.
? Moderate to severe hirsutism.
? Moderate to severe inflammatory acne vulgaris, which is also an indication to test for hyperandrogenemia.
Appropriate imaging criteria are not established for polycystic ovaries in adolescents.
? In adolescent females, large, multicystic ovaries are a common finding; therefore, ultrasonography is not a recommended investigation in patients younger than 17 years. .
Serum androgen levels
As an initial assessment, measure both total testosterone and sex hormone–binding globulin.
Obtain these tests in the follicular phase (days 1-13 of the menstrual cycle) so that values may be compared with a matched reference range. .
TreatmentGoals
• Eliminate or lessen severity of physical stigmata of hyperandrogenism (ie, acne, hirsutism).
• Restore normal menses (to avoid infertility and to protect against endometrial hyperplasia or carcinoma).
• Improve metabolic derangements and achieve normal glucose tolerance.
• Achieve and maintain BMI within reference range.
• Induce ovulation, if pregnancy is desired.
Treatment Options
Treatment involves addressing various disease components, including overweight and obesity, metabolic abnormalities, anovulation, acne, hirsutism, endometrial protection, infertility, and cardiovascular risk factors .
For most components of disease, primary treatment is weight loss through lifestyle modification.
Treatment options for anovulation
• Lifestyle modifications to achieve weight loss (at least 5% of body weight) can increase ovulation and pregnancy rates in some women. .
• Hormonal contraceptives are first line pharmacologic therapy to treat menstrual irregularity for patients who are not trying to become pregnant. Hormonal contraceptives also ameliorate features of hyperandrogenism (hirsutism and acne) and provide endometrial protection through withdrawal bleeding. .
• Consider metformin as second line therapy in patients who cannot take or do not tolerate hormonal contraceptives.
Treatment options to address overweight and to improve metabolic health
• First line therapy is lifestyle modification, which includes dietary changes and exercise, to achieve weight loss.
• Metformin may be added to target metabolic abnormalities (eg, impaired glucose tolerance, diabetes..
Treatment options for acne and hirsutism
• Base treatment on patient's degree of distress caused by hirsutism, rather than clinician's quantitative or qualitative assessments.
• Hormonal contraceptives are first line pharmacologic therapy.
• Nonpharmacologic cosmetic therapies for hirsutism include shaving, depilating, hair bleaching, electrolysis, and laser hair removal.
Monitoring
Long-term monitoring of cardiometabolic risk factors: Once diagnosis of polycystic ovary syndrome is made, evaluate and screen longitudinally for cardiometabolic risk factors.
? Type 2 diabetes
? Perform oral glucose tolerance test, repeated every 3 to 5 years depending on various factors such as degree of overweight or obesity, presence of central adiposity, and interval weight gain.
? Obesity
? Annually calculate BMI and measure waist circumference
? Depression and anxiety
? Periodically assess with a validated screening tool such as those of the Patient Health Questionnaire series
? Obstructive sleep apnea
? Screen with symptom assessment, and if apparent apnea/hypopnea is identified, obtain polysomnography.
? Dyslipidemia
? Obtain fasting lipid levels semiannually
? Hypertension
? Screen with blood pressure measurement at each office visit
Prevention
Loss of body weight has been shown to ameliorate some aspects of polycystic ovary syndrome, including hirsutism and anovulation; although not formally proven in well-designed trials, it is reasonable to advise measures to attain and maintain a BMI within reference range in adolescent and reproductive-aged women.