Polycystic Ovarian Syndrome
Imagine a condition that affects millions yet remains enshrouded in misconceptions. Polycystic Ovary Syndrome (PCOS) is just that – a prevalent but often misunderstood health challenge faced by women globally. In this blog post, we’re peeling back the layers of PCOS, a condition that affects approximately 8-13% of women of reproductive age. From the nuances of its diagnosis to the complexities of its treatment, we’ll dive into what makes PCOS a unique and critical issue in women’s health. Join us on this enlightening journey as we explore the latest findings and strive to demystify one of the most common endocrinologic disorders today.
To understand PCOS better, I’ll be summarizing key findings from a crucial article published in the Journal of Clinical Endocrinology & Metabolism (JCEM) titled “Update on PCOS: Consequences, Challenges, and Guiding Treatment.” This blog post marks the beginning of a multi-part series where we will delve deeper into the topic of PCOS. We will explore various aspects of PCOS, including its causes, symptoms, treatment options, and lifestyle management. Please stay tuned for upcoming articles in this series as we aim to provide a comprehensive understanding of PCOS.
Pathophysiology
The pathogenesis of PCOS is intricate, involving genetic, environmental, and transgenerational factors. These factors contribute to imbalanced hypothalamus-pituitary-ovarian axis signaling, resulting in ovarian and adrenal hyperandrogenism and insulin resistance. This intricate interplay manifests in a wide spectrum of metabolic, reproductive, and psychological issues. PCOS is influenced by genetic factors, with multiple risk gene loci identified, and it often clusters within families. Additionally, daughters of mothers with PCOS have a heightened risk of inheriting the syndrome, suggesting a transgenerational component. These complex relationships underline the need for comprehensive research to understand the full scope of PCOS
Diagnosis
Recent research highlights a substantial gap in applying this evidence to enhance diagnostic accuracy and treatment efficacy. Moreover, there remains a notable discrepancy in knowledge across various medical disciplines like Obstetrics and Gynecology (OBGYN), Medicine, Pediatrics, and Dermatology. This gap often leads to delayed diagnoses, patient dissatisfaction with treatment, and a lack of effective treatment options. A recent survey revealed that while a majority of OBGYN trainees in the U.S. use the Rotterdam criteria for diagnosing PCOS, only a fraction accurately identify all three main criteria required for diagnosis¹.
The diagnosis of PCOS is intricate and lacks a specific test. It relies on three key criteria:
Irregular menstrual cycles (oligo-anovulation),
Elevated androgen levels (clinical or biochemical),
Assessment of ovarian morphology via ultrasound.
Adult diagnosis requires the presence of at least two of these criteria according to the Rotterdam criteria. It’s essential to rule out other conditions like thyroid disease, hyperprolactinemia, and nonclassic congenital adrenal hyperplasia.
Severe androgen excess indicates significantly elevated androgen levels, exceeding double the upper limits of normal. This elevation can lead to observable signs like hirsutism, acne, or hair loss. However, it’s important to note that there is significant variation in androgenic expression among different ethnicities, making clinical assessment somewhat challenging. The guidelines recommend assessing androgen levels, but the interpretation of standardized measures like the modified Ferriman-Gallwey (mFG) score can be complex due to limited data from diverse populations. Nonetheless, androgen excess is a crucial diagnostic factor, especially when coupled with irregular menstrual cycles. The guidelines also introduce four phenotypes based on these criteria, and diagnosis complexities vary by age and ethnicity.
Complications of PCOS
Metabolic/Obesity
PCOS is linked to metabolic complications, including obesity, impaired glucose tolerance, type 2 diabetes, dyslipidemia, and hypertension. Obesity is a common concern, affecting 50% to 80% of individuals with PCOS. It’s associated with an increased risk of cardiovascular disease (CVD) risk factors. The risk of impaired glucose tolerance is three times higher, independent of BMI. Dyslipidemia, reflected by high triglycerides, is common, and there’s an association with hypertension, even in lean women with PCOS. Reproductive-age women with PCOS have a higher risk of metabolic syndrome, especially in the hyperandrogenic phenotype.
Fertility
PCOS can lead to endometrial hyperplasia and infertility due to anovulation. Premenopausal women with PCOS have a fourfold increased risk of endometrial cancer. Letrozole is associated with higher live birth rates for those seeking pregnancy. Metformin may help improve ovulation in obese women. During pregnancy, women with PCOS are at higher risk for miscarriage, gestational diabetes, pregnancy-induced hypertension, and preeclampsia, especially in hyperandrogenic phenotypes.
Behavioral & Emotional
PCOS is linked to a higher prevalence of psychiatric disorders, including depression and anxiety. Depressive and anxiety symptoms are increased, and some longitudinal studies support an increased risk of incident depression and anxiety. Psychological distress can persist long-term. Additionally, women with PCOS have a higher prevalence of disordered eating and body image distress, which can impact weight management. Routine screening and interventions like cognitive behavioral therapy are important in addressing these challenges.
Quality of Life
Living with PCOS can be challenging, and it affects our quality of life. Many patients with PCOS report feeling less healthy compared to those without the condition. It’s essential for both healthcare providers and women with PCOS to recognize the impact it has on overall well-being. This impact on health-related quality of life can persist into women’s late reproductive years. It’s crucial to address these challenges and work towards improving the quality of life for individuals with PCOS.
Further research needed:
Cardiovascular Disease: Research on cardiovascular risk factors like dyslipidemia, diabetes, and metabolic syndrome in older women with PCOS is limited and often based on small studies. More comprehensive assessments are needed across different PCOS phenotypes to provide accurate counseling. Some evidence suggests increased subclinical atherosclerosis in young women with PCOS, with higher risks of stroke and myocardial infarction. However, further longitudinal studies are required to assess cardiovascular events in this population accurately.
Perimenopausal Disease Course: Clinical features of PCOS tend to improve with age for many women. Menstrual cycles become more regular, and androgen levels normalize by the fourth decade. High levels of anti-Müllerian hormone (AMH) and antral follicle counts, indicating ovarian reserve, decrease with age. This suggests that women with PCOS may experience menopause later than those without the condition.
In closing, we acknowledge the challenges that individuals with PCOS face, from the complexities of diagnosis to the diverse range of symptoms and associated complications. PCOS can impact various aspects of life, from reproductive health to emotional well-being. It’s essential for healthcare providers and patients alike to recognize these challenges and work together to improve the quality of life for those with PCOS. We understand that navigating PCOS can be overwhelming, but there is hope, support, and a community ready to assist. Together, we can strive for a better understanding and management of this condition. Check back for our future blog posts on PCOS.
References
Chemerinski A , Cooney L, Shah D, Butts S, Gibson-Helm M, Dokras A. Knowledge of PCOS in physicians-in-training: identifying gaps and educational opportunities. Gynecol Endocrinol.2020;36(10):854-859
Kathleen M Hoeger, Anuja Dokras, Terhi Piltonen, Update on PCOS: Consequences, Challenges, and Guiding Treatment, The Journal of Clinical Endocrinology & Metabolism, Volume 106, Issue 3, March 2021, Pages e1071–e1083
