By Dr. Dineshani Hettiarachchi Sirisena Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that can affect up to 18% of women in their reproductive age. PCOS is predominantly a problem with hormones that affects women during their childbearing years (ages 15 to 44). Between 2.2-26.7% of women in this age group have PCOS and many of them don’t even know it. It is associated with a range of conditions, such as reproductive (hyperandrogenism, oligo, anovulation, or infertility), metabolic (gestational diabetes mellitus [GDM], impaired glucose tolerance [IGT], type two diabetes [T2DM], cardiovascular disease [CVD], cardiovascular risk factors), and psychological (depression, anxiety, poor self-esteem, disordered eating, psychosexual dysfunction), etc. As September is Polycystic Ovarian Syndrome Awareness Month, we spoke to Senior Lecturer and De Soysa Maternity Hospital Consultant Obstetrician and Gynecologist Dr. A.K. Probhodana Ranaweera (MBBS, MD, MRCOG) to shed light on this condition. Dr. Ranaweera likes to describe PCOS as a condition rather than a disease. It’s similar to someone being tall or short, having curly hair or straight hair; the main issue is genetic. However, there is a complex interplay with genes and the environment contributing to various presentations of PCOS. In susceptible individuals, due to their genetic predisposition, they develop resistance towards a hormone called insulin. Insulin is an anabolic hormone which is secreted soon after a meal and it controls food absorption and storage. When one develops resistance towards insulin, the level of the hormone in that individual is higher than normal. This leads to a greater percentage of food being stored as fat, thus leading to obesity. High insulin levels also increase testosterone, a male hormone. When testosterone levels are elevated in a female, it causes excess hair growth on the face and body, baldness, acne, and other typical features seen in patients with PCOS. The ovaries are relatively sensitive to these hormonal changes. Usually, once a month, an egg is released by the female ovary in a process called ovulation. Due to the hormonal imbalances in PCOS, this physiological process is hindered. As a result, the females’ ovaries develop a cyst, appearing due to the cessation of an egg being released every menstrual cycle (anovulation). Thus, PCOS patients have problems with their menstruation and getting pregnant. This hormonal imbalance causes them to skip menstrual periods. It can also contribute to long-term health problems such as diabetes and heart disease. Symptoms Signs and symptoms of PCOS often develop around the time of the first menstrual period during puberty. Sometimes, it develops later; for example, in response to substantial weight gain, signs and symptoms may vary. A diagnosis of PCOS is made when you experience at least two of these signs:

• Irregular periods – infrequent, irregular, or prolonged menstrual cycles are the most common sign of PCOS. For example, you might have fewer than nine periods a year, more than 35 days between periods, and abnormally heavy periods.
• Excess androgen – elevated levels of male hormones may result in physical signs such as excess facial and body hair (hirsutism), and occasionally severe acne and male-pattern baldness.
• Polycystic ovaries – your ovaries might be enlarged and contain follicles that surround the eggs. As a result, the ovaries might fail to function regularly.

PCOS signs and symptoms are typically more severe if you’re obese. (Source: Mayo clinic) There is no single test to diagnose PCOS. To help diagnose and rule out other causes of your symptoms, your doctor may talk to you about your medical history and do a physical examination and different tests.

• Physical examination – your doctor will measure your blood pressure, body mass index (BMI), and waist size. They will also look at your skin for extra hair on your face, chest, or back; acne; or skin discoloration. Your doctor may look for any hair loss or signs of other health conditions (such as an enlarged thyroid gland).
• Pelvic examination – your doctor may do a pelvic exam for signs of extra male hormones (for example, an enlarged clitoris) and check to see if your ovaries are enlarged or swollen.
• Pelvic ultrasound (sonogram) – this test uses sound waves to examine your ovaries for cysts and check the endometrium (lining of the uterus or womb).
• Blood tests – blood tests check your androgen hormone levels, sometimes called “male hormones”. Your doctor will also check for other hormones related to other common health problems that can be mistaken for PCOS, such as thyroid disease. Your doctor may also test your cholesterol levels and test you for diabetes.

Complications Complications of PCOS can include:

• Infertility
• Gestational diabetes or pregnancy-induced high blood pressure
• Miscarriage or premature birth
• Non-alcoholic steatohepatitis – a severe liver inflammation caused by fat accumulation in the liver
• Metabolic syndrome – a cluster of conditions including high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels that significantly increase your risk of cardiovascular disease

Type two diabetes or prediabetes

• Sleep apnea
• Depression, anxiety, and eating disorders
• Abnormal uterine bleeding
• Cancer of the uterine lining (endometrial cancer)

Pregnancy and PCOS PCOS interrupts the normal menstrual cycle and makes it harder to get pregnant. Between 70-80% of women with PCOS have fertility problems. It can also increase pregnancy-related complications and miscarriages. Weight loss and other treatments can improve your odds of having a healthy pregnancy. Having PCOS does not mean you can’t get pregnant. PCOS is one of the most common, but treatable, causes of infertility in women. Treatment Treatment focuses on managing your individual concerns, such as infertility, hirsutism, acne, or obesity. Specific treatment might involve lifestyle changes or medication. Lifestyle changes Your doctor may recommend weight loss through a low-calorie diet combined with moderate exercise activities. Even a modest reduction in your weight, for example, losing 5% of your body weight, might improve your condition. Losing weight may also increase the effectiveness of medications your doctor recommends for PCOS and can help with infertility. Lifestyle and home remedies To help decrease the effects of PCOS, try to:

• Maintain a healthy weight – weight loss can reduce insulin and androgen levels and may restore ovulation. Ask your doctor about a weight-control programme, and meet regularly with a dietician for assistance in reaching weight-loss goals.
• Limit carbohydrates – low-fat, high-carb diets might increase insulin levels. Ask your doctor about a low-carb diet if you have PCOS. Choose complex carbohydrates which raise your blood sugar levels more slowly.
• Be active – exercise helps lower blood sugar levels. If you have PCOS, increasing your daily activity and participating in a regular exercise programme may treat or even prevent insulin resistance and help you keep your weight under control and avoid developing diabetes.

To regulate your menstrual cycle, your doctor might recommend oral contraceptive pills, and medications such as metformin might be utilised to lower insulin resistance. Researchers continue to search for new ways to treat PCOS. Some current studies focus on genetics, environmental exposure, ethnic and racial differences, obesity and its link to PCOS, etc. Key take-home messages

• It’s a common condition
• One has to learn to live with the condition by making healthy lifestyle choices
• Diet and exercise play a major rule in controlling symptoms
• Cosmetic procedures are available for excess hair growth and acne
• Try and complete your family as soon as possible if you suffer from PCOS
• If you have vaginal bleeding after menopause, get yourself checked for endometrial cancer
• Control blood sugar and get yourself regularly tested for diabetes and heart disease

There is another subset of patients who have PCOS but who are not overweight. This group is poorly understood as some of them might not respond to the conventional treatment regimes. However, majority of those with this condition respond well by watching their diet and by increasing physical activity levels. The primary goal is to reduce insulin spikes which can be achieved by reducing snacking in between meals and by lowering your carbohydrate intake. If you opt to get a personal trainer or join a gym, you should be on a weight reduction schedule. If your BMI is high, you should aim at gradual weight loss. For example, aim at initially losing 3 kg in three months. This type of weight loss regime is achievable and can improve motivation, which is a key element to consistency as we are looking at long-term, sustainable weight loss. He also stated that there are misconceptions around using oral contraceptive pills in unmarried women to treat hormonal imbalances. Many believe that it can lead to subfertility later on, which is not true. By regulating the cycles their fertility, chances will increase. Usually, after a few months, they resume ovulation and have regular cycles, at which point they can discontinue using oral contraceptive pills. Finally, Dr. Ranaweera emphasised that with proper lifestyle changes, it is possible to live a healthy, happy life with PCOS. About the writer The writer, Dr. Dineshani Hettiarachchi Sirisena, is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka.