What is polycystic ovarian syndrome(PCOS)?
Patients with PCOS have a number of small underdeveloped follicles present on the outer surface of their ovaries. These follicles are often less than 8mm in size and have failed to develop due to a hormone imbalance. These ‘cyst’ lie structure are evident in her ultrasound scan of her ovaries that was included in the scenario.
Causes of PCOS
The exact cause of PCOS remains unknown but there appears to be a genetic component because it often runs in families. PCOS develops when the ovaries are overstimulated to produce excessive amounts androgens by high levels of luteinizing hormone(LH) that are released from the anterior pituitary gland and high levels of insulin. Patients may have high levels of testosterone and LH. High levels of LH may lead to the hypertrophy of the theca interna which causes the ovaries to increase its androstenedione and testosterone production. High levels of LH may also be responsible preventing the maturation of oocyte when they complete their first meiotic cycle. PCOS is often seen in patients who are overweight. These individuals are often insulin resistant because the normal amounts of insulin they produce is unable to transport glucose into fat and muscle tissues from the blood. Therefore more insulin is often produced by the pancreases and this causes a state of hyperinsulinemia. High levels of insulin can cause the ovaries to produce too much testosterone which disrupts the development of the follicle and therefore prevents normal ovulation from occurring because the ovum becomes stops developing properly in the ovaries.
Symptoms of PCOS
There are a number of symptoms associated with PCOS. Patient often have trouble conceiving because anovulation is occurring. This appear to be the major concern for the couples. The patient may also experience oligomenorrhoea where their periods have become infrequent. Other patients may experience amenorrhoea where the periods may become absent. These changes in the menstrual cycle can increase the risk of endometrial cancer because the lining of the endometrium is not being shed on a monthly basis and also because patients with PCOS often have high levels of oestrogen which can cause the lining of the endometrium to stay intact. Patient also has notice increased facial hair growth, this is known as hirtuism. This is due to the androgens having a growth promoting effect on the hair follicle. Other patients may experience extra hair growth around their forearms, lower legs and on the abdomen. Patients may also notice an increase in weight. This could be due to patients with PCOS being insulin resistant which causes failure of glucose absorption and therefore excess glucose is turned into fat which will be stored.
Other symptoms which patients often experience include acne, acanthosis nigricans (areas of increased skin pigmentation) and the risk of miscarriage increases.
Diagnosis of PCOS
Patients who present with hirtuism and menstrual cycle disturbances are often diagnosed with PCOS. However, before the patient is diagnosed with PCOS other rarer conditions which cause similar symptoms such as late onset congenital adrenal hyperplasia, Cushing’s syndrome, ovarian and adrenal tumours need to be excluded. Blood tests can be are taken to determine levels of luteinising hormone, testosterone, insulin, glucose and cholesterol. An ultrasound scan is carried out to confirm the diagnosis of PCOS. A patient confirmed with this condition will show a number of cyst like structure on the outer surface of the ovaries which looks rather like a pearl necklace.
Treatment of PCOS
PCOS cannot be cured but treatment can be provided with the aims of reducing hirtuism, inducing regular periods and improving fertility which would all be beneficial. Cyproterone acetate can be used to lower testosterone levels in order to reduce growth of unwanted hair on face as well as using vaniqa cream to block the action of enzymes in hair follicles to prevent unwanted hair growth. Contraceptive pill or progestogen-only pill may can be used to induce regular periods and also reduce risk of endometrial cancer. Metformin can increase ovulation and improve effects of insulin resistance. For patients who would like to conceive clomifene can be given to stimulate ovulation. Surgical procedures such as laparoscopic ovarian drilling can be carried out to destroy the tissue areas which are causing excess androgens to be produced.