PCOS and Infertility

WHAT IS POLYCYSTIC OVARIAN SYNDROME (PCOS)

Polycystic ovarian syndrome (PCOS) is a hormonal disorder affecting around 15-25% of Indian women. It is called a ‘syndrome because it encompasses a number of symptoms experienced at the same time. As the name suggests, most women with PCOS have multiple small cysts in their ovaries. This need not necessarily be present in all women and a diagnosis of PCOS can be made by other symptoms which are detailed below.

WHAT CAUSES PCOS?

Doctors are not exactly certain what causes PCOS. Genetics may play a role, in other words- it runs in the family. If any relatives, such as your mother, sister or aunt have PCOS, the risk of you developing the disease is often increased.

Levels of insulin are found to be raised in women with PCOS. Insulin helps to regulate blood sugar levels. It is secreted by the pancreas following a meal and moves glucose from the blood into cells, where it is further broken down to produce energy. Women with PCOS are resistant to the actions of insulin (their tissues don’t respond to insulin), hence, more and more insulin is produced as compensation. These high levels of insulin cause the ovaries to produce excess testosterone. Moreover, insulin resistance and hyperinsulinemia can lead to weight gain, worsening the symptoms of PCOS, as having excess fat can further increase insulin resistance leading to more hyperinsulinemia. Thus, it is a vicious cycle of events.

The following hormones are found to be deranged in women with PCOS:

  • High levels of testosterone- It is found in small amounts in females but women with PCOS tend to produce higher levels and this is the cause of acne and excessive hair growth.
  • High levels of luteinffing hormone (LH) – This is responsible for ovulation but high levels may have an abnormal effect on the ovaries.
  • High levels of prolactin- Found only in some women with PCOS.

DO I HAVE PCOS?

Women with PCOS may exhibit the following symptoms: Irregular periods or no periods at all. Difficulty getting pregnant (because of irregular production or failure to produce an egg).

  • Excessive hair growth (hirsuitism) on the face, chest and hack.
  • Severe, worsening or treatment-resistant acne.
  • Thinning hair or hair loss from the head.
  • Weight gain.
  • Dark, velvety discoloration on the nape of the neck and underarms (acanthosis nigricans).

Not all women with PCOS have all of these symptoms. Some women experience menstrual problems or difficulty in conception or both, and are subsequently found to have PCOS.

HOW DOES IT AFFECT MY ABILITY TO CONCEIVE?

Polycystic ovaries have multiple tiny cysts (follicles). A follicle is a fluid-filled sac in the ovary which contains an egg. You may wonder women with PCOS have many follicles and if each contains an egg, aren’t the chances of natural conception higher? Well, more is not always better as is evidenced by this scenario. To understand why, let us look at the normal menstrual cycle. Every month or so, after your period, a few follicles start developing in your ovary under the influence of a hormone called follicle-stimulating hormone (FSH). Out of these follicles, only one undergoes complete maturation while the others regress. When that single follicle is ready, there is a surge of another hormone called luteinizing hormone (LH), which causes rupture of the follicle and release of the egg- the process called ovulation. In women with PCOS, due to the underlying hormonal imbalance, these follicles stop growing around halfway to maturity and ovulation does not happen. Therefore, an egg is not produced and conception is affected.

WHAT TESTS WILL I HAVE TO UNDERGO?

Your doctor will consider your symptoms and perform a physical examination, a few blood tests and a scan to look at your ovaries.

  • Physical examination: Your doctor will examine you for physical signs of PCOS- acne, excess hair growth, darkened skin and also check your weight.
  • Blood tests: Your blood may be tested for levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), free testosterone, Anti-Mullerian hormone (AMH) and blood sugar levels (for insulin resistance).
  • Transvaginal ultrasound: A long slender probe is inserted into the vagina to look at your ovaries (number of follicles) and also to look for any other abnormalities in your ovaries or uterus.

DIAGNOSTIC CRITERIA FOR PCOS: A diagnosis of PCOS is made after all other causes have been ruled out and you have 2 of the following 3 criteria: 1. Irregular/ no periods- indicate infrequent/ no ovulation. 2. Blood tests or symptoms suggestive of high levels of “male hormones” (11 rerandroienism . 3. Scans showing you have polycystic ovaries.

WHAT IS THE TREATMENT OF PCOS?

Polycystic ovarian syndrome cannot be cured but the symptoms can be alleviated with appropriate treatment. Treatment options may vary from person to person depending on the particular symptoms. These are discussed in more detail below.

LIFESTYLE CHANGES

In overweight women, weight loss is the key factor to regularize periods and reduce the risk of developing long-term health problems from PCOS. Weight loss of just 5-10% of your body weight can lead to a significant improvement in PCOS. You can find out if you’re a healthy weight by calculating your body mass index (BMI) which is a measurement of your weight in relation to your height. A normal BMI is from 18.5 to 24.9.

MEDICATIONS

  • To regularize cycles: The oral contraceptive pill is used to regularize your periods or induce a period (progesterone) if you haven’t bled in a cycle. It is important to ensure you bleed every month as this reduces the incidence of you developing endometrial cancer in the long run. There are a wide range of pills with differing doses of oestrogen and progesterone. Your doctor will i determine the right one for you. Some side effects include intermenstrual spotting, weight changes, mood changes and breast tenderness.
  • To induce ovulation: These include Letrozole, Clomiphene citrate and Gonadotropins or a combination or oral drugs and injectables.
  • To combat insulin resistance: Mettormin is usually used to treat type 2 diabetes but it can also lower insulin and blood sugar levels in women with PCOS. Side effects include nausea, vomiting and abdominal pain.
  • For excessive hair growth: This can be dealt with cosmetic methods such as waxing, shaving or laser removal. If you are not planning a pregnancy, oral contraceptive pills containing Cyproterone acetate can be used. They block the effects of androgen’s hence reducing hair growth. Eflornithine cream may be used to slow down the growth of facial hair and it is best used alongside a hair removal product.

SURGERY

If you do not respond to medications, you may be advised to undergo a procedure called laparoscopic ovarian drilling. This procedure helps to reduce male hormone levels and may aid ovulation.

WHAT ARE THE LONG-TERM RISKS OF PCOS?

  • PCOS is an independent risk factor for the development of type 2 diabetes in middle age.
  • Women with PCOS have a higher risk of developing cardiovascular disease and hypertension.
  • A cluster of symptoms, namely- impaired glucose tolerance, obesity and high cholesterol, termed ‘metabolic syndrome can occur in women with PCOS.
  • Infrequent or no periods in women with PCOS causes abnormal thickening of the lining of the uterus (endometrium) which can predispose to endometrial cancer.

HOW DO I REDUCE THESE RISKS?

Weight loss and physical activity as detailed above form the cornerstone of risk reduction strategies. They lower the risk of developing diabetes and cardiovascular disease in later life. It is advisable to make sure you have a period at least once every two months. This will ensure your uterine lining does not thicken too much thereby reducing your risk of developing endometrial cancer.

EVERY CLOUD HAS A SILVER LINING

The good news about PCOS is that your ovarian reserve (the number of eggs you have) is good. Therefore, your chances of getting pregnant with treatment (stimulation) are also good.

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