Polycystic Ovarian Syndrome (PCOS) is possibly the most common endocrine disorder afflicting women of reproductive age. Of late, PCOS has generated much interest, likely due to the increased media attention that this condition has generated.

WHAT IS PCOS?
PCOS is a complex hormonal disorder in which patients present with either oligo or amenorrhoea, features attributed to increased androgen secretion and, possibly, the polycystic appearance of the ovaries on ultrasound.

HOW IS PCOS DIAGNOSED?
The most commonly utilised method is referred to as the “Rotterdam criteria”, and this dictates that a diagnosis of PCOS may be made if the patient fulfils at least two of three criteria:

• Oligomenorrhoea or amenorrhoea
• Clinical features and/or biochemical evidence of hyperandrogenism
• Ultrasound appearende of polycystic ovaries

WHAT CAUSES PCOS?
Studies suggest a clear genetic link and PCOS is possibly polygenic in nature. The current belief is that a number of genetic variants interact with certain environmental factors to contribute to the pathophysiology of PCOS.

WHAT IS THE UNDERLYING PATHOPHYSIOLOGY IN PCOS?
The exact mechanism involved in the pathophysiology of PCOS is still unknown, but evidence available shows a distinct link between PCOS and insulin resistance (IR). Not all patients with PCOS have IR, and vice versa.

WHAT IS INSULIN RESISTANCE (IR)?
It has long been noted that most patients with PCOS have some degree of insulin resistance. The susceptibility towards developing IR is likely inherited, but the exact mechanism of inheritance is unknown. IR results in end organs not being able to utilise insulin effectively, which results in increased insulin production. Insulin has several functions, but a major consequence of this excess insulin production is enlarged ovaries with grossly increased ovarian androgen production.

WHAT IS THE TREATMENT FOR PCOS?
Subfertility is a common problem due to the anovulation, and so ovulation induction with clomiphene citrate would be the accepted first line of management. In patients that do not respond to clomiphene citrate, a reasonable next option would be to induce ovulation with either gonadotrophins or to undertake drilling of the ovaries.

If the main complaint is related to the excessive production of male hormones (causing hirsuitism, acne, or alopecia), the three main options available include cosmetic options like plucking, shaving, electrolysis and similar alternatives.

WHAT IS METFORMIN?
Metformin is used to reduce the insulin levels in the body. The reduced hyperinsulinaemia helps stem or reverse the sinister effects of excess insulin on the body.

ARE ALL PCOS PATIENTS CANDIDATES TO RECEIVE METFORMIN?
No. This is because current evidence on the beneficial effects of metformin appears inconsistent in PCOS patients. Inconsistencies in benefits are present when considering metformin for weight loss in PCOS patients, while for fertility patients the use of metformin seems more useful. Therefore, it is not currently recommended that metformin be prescribed to all PCOS patients.

SO HOW DO WE DIAGNOSE INSULIN RESISTANCE (IR)?
There is currently no reliable method for accurately measuring IR. The preferred method of assessing insulin resistance is by doing a glucose tolerance test and labelling all patients with an impaired result as having insulin resistance. Interestingly, evidence suggests that up to 10% of PCOS patients are found to have diabetes on initial presentation to the clinic.

WHAT ARE THE LONG TERM CONSEQUENCES OF PCOS?
PCOS patiets are at risk of a wide variety of long term problems, including reproductive difficulties as well as a risk of diabetes, endometrial hyperplasia and carcinoma, hypertension, and cardiovascular disease.

ROLE OF OBESITY
While not all PCOS patients are obese, most are. Obesity aggravates the condition by increasing insulin levels and insulin resistance. As previously mentioned, insulin resistance and increased insulin levels lead to hyperandrogenism and its associated anabolic effects, thus programming the body into a “body-building” mode which starts a vicious cycle of increased weight.

WHAT CAN BE DONE FOR PCOS PATIENTS IN THE LONG TERM?
Long term management is outlined by three fundamental principles:

• Determine the primary problem anddecide appropriate management. If a patients’ primary concern is subfertility, ovulation induction may be the most appropriate method.
• Consider weight loss, as it has beendemonstrated that weight loss in PCOS patients relieves many of the symptoms.  
• Think long term. The consequencesover time may be considerable, so doctors should remember to review patients periodically.

This article was written by Dr. Eeson Sinthamoney for The Expat magazine.
Source: The Expat August 2012
Register for free on ExpatGoMalaysia.com