POLYCYSTIC OVARY SYNDROME

A Presentation to the Women’s Wing of Charis World Bible Church, Oko Okonkwo Chinenye Maryrose RN, RM, RNAS, PDE, TRCN Directress/ Proprietress, Nneoma Maternity inc. and Member, National Association of Nigerian Nurses and Midwives and Association of General Private Nursing Practitioners. Date: 23/8/2024

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder affecting women of reproductive age. It is characterized by a combination of symptoms that may include irregular menstrual periods, excess androgen levels (male hormones), and polycystic ovaries. Despite its name, not all women with PCOS have ovarian cysts, and the condition can vary widely in its presentation.

Understanding PCOS

1. Definition and Diagnostic Criteria

PCOS is defined by the presence of at least two of the following three criteria (known as the Rotterdam criteria):
  • Irregular or Infrequent Ovulation: This often manifests as irregular menstrual cycles, which can be less frequent than normal (oligomenorrhea) or absent (amenorrhea).
  • Hyperandrogenism: Elevated levels of male hormones (androgens) In the body can lead to physical symptoms such as hirsutism (excessive hair growth, especially on the face and body), acne, and androgenic alopecia (male-pattern baldness).
  • Polycystic Ovaries: On ultrasound, the ovaries may appear enlarged and contain numerous small follicles (often referred to as cysts, though they are actually immature ovarian follicles).
PCOS is a diagnosis of exclusion, meaning that other conditions that could cause similar symptoms (such as thyroid disorders, adrenal hyperplasia, or prolactin-secreting tumors) need to be ruled out before confirming a PCOS diagnosis.

2. Epidemiology

  • Prevalence: PCOS is one of the most common endocrine disorders in women of reproductive age, affecting approximately 5-10% of women globally.
  • Age of Onset: Symptoms often start during puberty or early adulthood, but the condition can also be diagnosed later in life, especially when symptoms are mild or menstrual Irregularities are initially overlooked.

3. Pathophysiology

The exact cause of PCOS is not fully understood, but it is believed to involve a combination of genetic, hormonal, and environmental factors:
  • Insulin Resistance and Hyperinsulinemia: Many women with PCOS have insulin resistance, meaning their body’s cells do not respond effectively to insulin. This leads to higher insulin levels, which can exacerbate hyperandrogenism by stimulating the ovaries to produce more androgens and reducing the liver’s production of sex harmone-binding globulin (SHBG), which increases the amount of free androgens in the body.
  • Hormonal Imbalance: In PCOS, the balance of reproductive hormones is disrupted. For instance, the pituitary gland may secrete an abnormal ratio of luteinizing hormone (LH) to follicle-stimulating hormone (FSH), which can impair ovulation. Elevated levels of androgens and Insulin further contribute to this hormonal imbalance.
  • Genetic Factors: PCOS tends to run in families, suggesting a genetic component. Women with a mother or sister who has PCOS are at higher risk of developing the condition.

Symptoms of PCOS

PCOS symptoms can vary significantly among women and can range from mild to severe. Some of the most common symptoms include:

1. Menstrual Irregularities:

  • Irregular periods are a hallmark of PCOS. This can manifest as fewer than eight periods a year, cycles that are more than 35 days apart, or prolonged periods that are abnormally heavy or light.
  • Some women with PCOS may experience amenorrhea, or the complete absence of menstruation.

2. Hyperandrogenism:

  • Hirsutism: Excessive hair growth on the face, chest, back, or buttocks.
  • Acne: Persistent and often severe acne… typically on the face, chest, and back.
  • Androgenic Alopecia: Thinning hair or male-pattern baldness.

3. Polycystic Ovaries:

  • On an ultrasound, ovaries may appear enlarged and contain multiple small follicles (typically more than 12 on each ovary) that resemble cysts.
  • Not all women with PCOS will have polycystic ovaries, and not all women with polycystic ovaries have PCOS.

4. Weight Gain and Obesity:

  • Many women with PCOS are overweight or obese, particularly with an “apple-shaped” body, where weight is carried around the abdomen.
  • Weight gain can exacerbate insulin resistance and hormonal imbalances, leading to a vicious cycle.

5. Fertility Issues:

  • PCOS is one of the leading causes of infertility due to anovulation (lack of ovulation). However, many women with PCOS can conceive with appropriate treatment.

6. Skin Changes:

  • Acanthosis Nigricans: Dark, velvety patches of skin, usually found in body folds such as the neck, groin, and underarms, associated with insulin resistance.
  • Skin Tags: Small, excess skin growths that may appear in areas like the neck and armpits.

7. Psychological Symptoms:

  • Women with PCOS are at higher risk for anxiety, depression, and other mood disorders, possibly due to the hormonal imbalances, the physical symptoms (such as hirsutism or weight gain), and the challenges associated with infertility.

Complications of PCOS

PCOS is associated with several long-term health risks, including:

1. Metabolic Syndrome:

  • This cluster of conditions includes obesity, high blood pressure, high blood sugar, and abnormal cholesterol levels, Increasing the risk of cardiovascular disease.

2. Type 2 Diabetes:

  • Insulin resistance associated with PCOS can lead to type 2 diabetes. Women with PCOS are at increased risk of developing diabetes, especially if they are overweight or obese.

3. Cardiovascular Disease:

  • Women with PCOS have an elevated risk of heart disease, possibly due to the combination of insulin resistance, obesity, and dyslipidemia (abnormal cholesterol levels).

4. Endometrial Cancer:

  • Chronic anovulation and prolonged exposure to unopposed estrogen (without progesterone) can increase the risk of endometrial hyperplasia and, subsequently, endometrial cancer.

5. Sleep Apnea:

  • Obesity, common in women with PCOS, can contribute to obstructive sleep apnea, a condition where breathing repeatedly stops and starts during sleep.

Diagnosis of PCOS

Diagnosing PCOS involves a combination of medical history, physical examination, blood tests, and imaging studies:

1. Medical History:

  • A thorough review of menstrual history, symptoms of hyperandrogenism, and family history of PCOS or other metabolic conditions.

2. Physical Examination:

  • Assessment for signs of hyperandrogenism (e.g., hirsutism, acne), obesity, and other physical findings such as acanthosts nigricans.

3. Blood Tests:

  • Hormonal assays to measure levels of androgens, LH, FSH, prolactin, and thyroid function. Tests for glucose tolerance and lipid profile are also essential to assess metabolic risks.

4. Ultrasound:

  • A transvaginal ultrasound may be performed to evaluate the ovaries for the presence of multiple follicles and assess the endometrial lining

5. Exclusion of Other Conditions:

  • Conditions such as thyroid disorders, hyperprolactinemia, and congenital adrenal hyperplasia must be excluded before confirming a diagnosis of PCOS.

Treatment and Management of PCOS

There is no cure for PCOS, but the symptoms can be managed effectively through lifestyle changes, medications, and in some cases, surgical Interventions. Treatment is often tailored to the Individual’s symptoms and goals, such as managing hirsutism, regulating menstrual cycles, or improving fertility.

1. Lifestyle Modifications:

  • Diet and Exercise: Weight loss through a balanced diet and regular exercise is often the first line of treatment. Even a 5-10% reduction in body weight can significantly improve symptoms and reduce the risk of complications.
  • Healthy Eating: A diet low in refined carbohydrates and rich in whole grains, fruits, vegetables, and lean proteins can help manage Insulin levels and support weight loss.
  • Physical Activity: Regular aerobic exercise and strength training can Improve Insulin sensitivity, help with weight management, and reduce the risk of cardiovascular disease.

2. Medications:

  • Hormonal Contraceptives: Birth control pills, patches, or vaginal rings that contain estrogen and progestin can regulate menstrual cycles, reduce androgen levels, and improve symptoms like acne and hirsutism.
  • Anti-Androgens: Medications such as spironolactone can block the effects of androgens on the skin, reducing hirsutism and acne.
  • Metformin: Commonly used in type 2 diabetes, metformin can improve insulin sensitivity, lower insulin levels, and help with weight loss. It may also regulate menstrual cycles.
  • Clomiphene Citrate (Clomid): A fertility medication that stimulates ovulation, often used in women with PCOS who are trying to conceive.
  • Letrozole (Femara): Another ovulation-inducing medication, which may be more effective than clomiphene in some women with PCOS.
  • Gonadotropins: Injectable hormones used in more advanced fertility treatments, such as in vitro fertilization (IVF).

3. Surgical Treatment:

  • Ovarian Drilling: A laparoscopic procedure in which small holes are drilled into the ovarian surface to reduce androgen production. This is typically reserved for women who do not respond to other treatments.

4. Cosmetic Treatments:

  • Hair Removal: Methods like laser hair removal or electrolysis can permanently reduce unwanted hair growth. Topical creams such as eflornithine can also slow the growth of facial hair.
  • Acne Treatment: Dermatological treatments, including topical or oral antibiotics, retinoids, and hormonal therapy, can manage acne.

Fertility and Pregnancy with PCOS

While PCOS is a leading cause of infertility, many women with the condition can conceive with the right treatment:
  1. Ovulation Induction: Medications like clomiphene or letrozole can induce ovulation, improving the chances of conception.
  2. Assisted Reproductive Technology (ART): In cases where ovulation Induction is not successful, ART such as Intrauterine Inseminat n (IUI) or IVF may be recommended.
  3. Lifestyle Modifications: Weight loss can restore ovulation In many women with PCOS, enhancing fertility.
  4. Pregnancy Risks: Women with PCOS are at higher risk for complications such as gestational diabetes, preeclampsia, and preterm birth. Regular prenatal care and close monitoring are essential.

Long-Term Management

PCOS is a chronic condition that requires ongoing management to reduce the risk of complications and improve quality of life:
  1. Regular Monitoring: Periodic assessment of blood pressure, glucose levels, and lipid profiles is essential to monitor for metabolic syndrome and cardiovascular risks.
  2. Mental Health Support: Given the higher risk of anxiety and depression, mental health support, including counselling and, if necessary, medication, may be beneficial.
  3. Continued Lifestyle Management: Maintaining a healthy weight, regular physical activity, and a balanced diet are crucial in long-term management.

Conclusion

Polycystic Ovary Syndrome is a complex and multifaceted condition that affects various aspects of a woman’s health, from reproductive function to metabolic and psychological well-being. While there is no cure, with proper management, women with PCOS can lead healthy, fulfilling lives. Understanding the condition, seeking appropriate medical care, and making informed lifestyle choices are key to managing PCOS effectively

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