Polycystic ovary syndrome

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(Redirected from
PCOS
)
"PCOS" redirects here. For other uses, see PCOS (disambiguation).
Polycystic ovary syndrome
Other namesHyperandrogenic anovulation (HA),[1] Stein-Leventhal syndrome
anti-androgens[12]
Frequency2% to 20% of women of childbearing age[8][13]

Polycystic ovary syndrome, or polycystic ovarian syndrome (PCOS), is the most common

ovaries of some people with this condition, though this is not a universal symptom, and not the underlying cause of the disorder.[15][16]

Women with PCOS may experience irregular

heavy periods, excess hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin.[3] The primary characteristics of this syndrome include: hyperandrogenism, anovulation, insulin resistance, and neuroendocrine disruption.[17]

A review of international evidence found that the prevalence of PCOS could be as high as 26% among some populations, though ranges between 4% and 18% are reported for general populations.[18][19][20]

The exact cause of PCOS remains uncertain, and treatment involves management of symptoms using medication.[19]

Definition

Two definitions are commonly used:

  • NIH
In 1990, a consensus workshop sponsored by the
NICHD suggested that a person has PCOS if they have all of the following:[21]
  1. oligoovulation
  2. signs of
    androgen excess
    (clinical or biochemical)
  3. exclusion of other disorders that can result in menstrual irregularity and hyperandrogenism (e.g.: Congenital Suprarrenal Hyperplasia, androgen producer tumors, hyperprolactinemia).
  • Rotterdam

In 2003, a consensus workshop sponsored by

ASRM in Rotterdam indicated PCOS to be present if any two out of three criteria are met, in the absence of other entities that might cause these findings:[22][23][24]

  1. oligoovulation and/or anovulation
  2. excess androgen activity
  3. polycystic ovaries (by
    gynecologic ultrasound
    )

The Rotterdam definition is wider, including many more women, the most notable ones being women without androgen excess. Critics say that findings obtained from the study of women with androgen excess cannot necessarily be extrapolated to women without androgen excess.[25][26]

  • Androgen Excess PCOS Society
In 2006, the Androgen Excess PCOS Society suggested a tightening of the diagnostic criteria to all of the following:[22]
  1. excess androgen activity
  2. oligoovulation/anovulation and/or polycystic ovaries
  3. exclusion of other entities that would cause excess androgen activity

Signs and symptoms

Signs and symptoms of PCOS include irregular or no

heavy periods, excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin,[3] ovarian cysts, enlarged ovaries, excess androgen, and weight gain.[27][28]

Associated conditions include

heart disease, mood disorders, and endometrial cancer.[4]

Further information: Infertility in polycystic ovary syndrome

Common signs and symptoms of PCOS include the following:

  • Menstrual disorders: PCOS mostly produces oligomenorrhea (fewer than nine menstrual periods in a year) or amenorrhea (no menstrual periods for three or more consecutive months), but other types of menstrual disorders may also occur.[22]
  • Infertility: This generally results directly from chronic anovulation (lack of ovulation).[22]
  • hyperandrogenemia.[30]
  • central obesity and other symptoms associated with insulin resistance, including low energy levels and food cravings.[22] Serum insulin, insulin resistance, and homocysteine levels are higher in women with PCOS.[31]
  • Acne: A rise in testosterone levels, increases the oil production within the sebaceous glands and clogs pores.[32] For many people, the emotional impact is great and quality of life can be significantly reduced.[33]
  • Androgenic Alopecia: Estimates suggest that androgenic alopecia affects 22% of PCOS sufferers.[32] This is a result of high testosterone levels that are converted into the dihydrotestosterone (DHT) hormone. Hair follicles become clogged, making hair fall out and preventing further growth.[34]
  • Acanthosis Nigricans (AN): A skin condition where dark, thick and "velvety" patches can form. (p. 141)[35]
  • Polycystic ovaries: PCOS is a complicated disorder characterized by high androgen levels, irregular menstruation, and/or small cysts on one or both ovaries. Ovaries might get enlarged and comprise follicles surrounding the eggs. As result, ovaries might fail to function regularly. This disease is related to the number of follicles per ovary each month growing from the average range of 6-8 to double, triple or more[citation needed]. Women with PCOS have higher risk of multiple diseases including Infertility, type 2 diabetes mellitus (DM-2), cardiovascular risk, metabolic syndrome, obesity, impaired glucose tolerance, depression, obstructive sleep apnea (OSA), endometrial cancer, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH).[36]

Women with PCOS tend to have central obesity, but studies are conflicting as to whether visceral and subcutaneous abdominal fat is increased, unchanged, or decreased in women with PCOS relative to non-PCOS women with the same body mass index.[37] In any case, androgens, such as testosterone, androstanolone (dihydrotestosterone), and nandrolone decanoate have been found to increase visceral fat deposition in both female animals and women.[38]

Although 80% of PCOS presents in women with obesity, 20% of women diagnosed with the disease are non-obese or "lean" women.[39] However, obese women that have PCOS have a higher risk of adverse outcomes, such as hypertension, insulin resistance, metabolic syndrome, and endometrial hyperplasia.[40]

Even though most women with PCOS are overweight or obese, it is important to acknowledge that non-overweight women can also be diagnosed with PCOS. Up to 30% of women diagnosed with PCOS maintain a normal weight before and after diagnosis. "Lean" women still face the various symptoms of PCOS with the added challenges of having their symptoms properly addressed and recognized. Lean women often go undiagnosed for years, and usually are diagnosed after struggles to conceive.[41] Lean women are likely to have a missed diagnosis of diabetes and cardiovascular disease. These women also have an increased risk of developing insulin resistance, despite not being overweight. Lean women are often taken less seriously with their diagnosis of PCOS, and also face challenges finding appropriate treatment options. This is because most treatment options are limited to approaches of losing weight and healthy dieting.[42]

Hormone levels

tumor, may be present and should be excluded.[45][48][43]

Associated conditions

Warning signs may include a change in appearance. But there are also manifestations of mental health problems, such as anxiety, depression, and eating disorders.[27][medical citation needed]

A diagnosis of PCOS suggests an increased risk of the following:

The risk of ovarian cancer and breast cancer is not significantly increased overall.[49]

Cause

PCOS is a

androgens and the anti-Müllerian hormone (AMH) in utero increases the risk of developing PCOS in later life.[64]

It may be caused by a combination of genetic and environmental factors.

high blood levels of prolactin.[9]

Genetics

The genetic component appears to be inherited in an

baldness and/or excessive hair) and daughters, who will show signs of PCOS.[66][68] The phenotype appears to manifest itself at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele.[67] The exact gene affected has not yet been identified.[7][63][69] In rare instances, single-gene mutations can give rise to the phenotype of the syndrome.[70] Current understanding of the pathogenesis of the syndrome suggests, however, that it is a complex multigenic disorder.[71]

Due to the scarcity of large-scale screening studies, the prevalence of endometrial abnormalities in PCOS remains unknown, though women with the condition may be at increased risk for endometrial hyperplasia and carcinoma as well as menstrual dysfunction and infertility.

The severity of PCOS symptoms appears to be largely determined by factors such as obesity.[7][22][72] PCOS has some aspects of a metabolic disorder, since its symptoms are partly reversible. Even though considered as a gynecological problem, PCOS consists of 28 clinical symptoms.[73]

Even though the name suggests that the ovaries are central to disease pathology, cysts are a symptom instead of the cause of the disease. Some symptoms of PCOS will persist even if both ovaries are removed; the disease can appear even if cysts are absent. Since its first description by Stein and Leventhal in 1935, the criteria of diagnosis, symptoms, and causative factors are subject to debate. Gynecologists often see it as a gynecological problem, with the ovaries being the primary organ affected. However, recent insights show a multisystem disorder, with the primary problem lies in hormonal regulation in the hypothalamus, with the involvement of many organs. The term PCOS is used due to the fact that there is a wide spectrum of symptoms possible. It is common to have polycystic ovaries without having PCOS; approximately 20% of European women have polycystic ovaries, but most of those women do not have PCOS.[15]

Environment

PCOS may be related to or worsened by exposures[

epigenetic factors, environmental impacts (especially industrial endocrine disruptors, such as bisphenol A and certain drugs)[77][78][79] and the increasing rates of obesity.[78]

dioxins and triclosan. Endocrine disruptors can cause adverse health impacts in animals.[80] Additional research is needed to assess the role that endocrine disruptors may play in disrupting reproductive health in women and possibly triggering or exacerbating PCOS and its related symptoms.[81]

Pathogenesis

Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgenic hormones, in particular testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility):[67]

  • the release of excessive luteinizing hormone (LH) by the anterior pituitary gland
  • through high levels of insulin in the blood (
    hyperinsulinaemia
    ) in women whose ovaries are sensitive to this stimulus

A majority of women with PCOS have

17α-hydroxylase, which catalyzes the conversion of progesterone to androstenedione, which is in turn converted to testosterone. The combined effects of hyperinsulinemia contribute to an increased risk of PCOS.[82]

Adipose (fat) tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese women creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and excess estrogens (which inhibit FSH via negative feedback).[84]

The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian

ovarian follicles. The follicles have developed from primordial follicles, but this development has stopped ("arrested") at an early stage, due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.[85]

PCOS may be associated with

chronic inflammation,[86] with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.[87][88] Similarly, there seems to be a relation between PCOS and an increased level of oxidative stress.[89]

Diagnosis

Not every person with PCOS has polycystic ovaries (PCO), nor does everyone with

pelvic ultrasound is a major diagnostic tool, it is not the only one.[90] The diagnosis is fairly straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms.[91]

  • Transvaginal ultrasound scan of polycystic ovary
    Transvaginal ultrasound scan of polycystic ovary
  • Polycystic ovary as seen on sonography
    Polycystic ovary as seen on sonography

Differential diagnosis

Other causes of irregular or absent menstruation and hirsutism, such as

hyperprolactinemia (leading to anovulation), androgen-secreting neoplasms, and other pituitary or adrenal disorders, should be investigated.[22][24][92]

Assessment and testing

Standard assessment

  • History-taking, specifically for menstrual pattern, obesity, hirsutism and acne. A
    specificity of 93.8% (95% CI 82.8%–98.7%).[93]
  • ovarian follicles. These are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – in essence, a cyst that bursts to release the egg. After ovulation, the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so-called "follicular arrest"; i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, which are widely used for diagnosis of PCOS,[10] 12 or more small follicles should be seen in a suspect ovary on ultrasound examination.[21] More recent research suggests that there should be at least 25 follicles in an ovary to designate it as having polycystic ovarian morphology (PCOM) in women aged 18–35 years.[94] The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'.[95] If a high-resolution transvaginal ultrasonography machine is not available, an ovarian volume of at least 10 ml is regarded as an acceptable definition of having polycystic ovarian morphology. rather than follicle count.[94]
  • Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. (This would usually be an incidental finding if laparoscopy were performed for some other reason, as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)[96]
  • Serum (blood) levels of
    free testosterone level is thought to be the best measure,[92][98] with approximately 60 per cent of PCOS patients demonstrating supranormal levels.[30]

Some other blood tests are suggestive but not diagnostic. The ratio of LH (

cut-offs to designate abnormally high LH/FSH ratios are 2:1[99] or 3:1[92] as tested on day 3 of the menstrual cycle. The pattern is not very sensitive; a ratio of 2:1 or higher was present in less than 50% of women with PCOS in one study.[99] There are often low levels of sex hormone-binding globulin,[92] in particular among obese or overweight women.[100]
Anti-Müllerian hormone (AMH) is increased in PCOS, and may become part of its diagnostic criteria.[101][102][103]

Glucose tolerance testing

  • Two-hour oral glucose tolerance test (GTT) in women with risk factors (obesity, family history, history of gestational diabetes)[22] may indicate impaired glucose tolerance (insulin resistance) in 15–33% of women with PCOS.[92] Frank diabetes can be seen in 65–68% of women with this condition.[104] Insulin resistance can be observed in both normal weight and overweight people, although it is more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of people with PCOS may have insulin resistance at some level.[22]
  • Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women needing higher doses of metformin or the use of a second medication to significantly lower insulin levels. Elevated
    blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. A mathematical derivation known as the HOMAI, calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).[105]

Management

PCOS has no cure.[5] Treatment may involve lifestyle changes such as weight loss and exercise.[10][11]

Recent research suggests that daily exercise including both aerobic and strength activities can improve hormone imbalances.[106]

Birth control pills may help with improving the regularity of periods, excess hair growth, and acne.[12] Combined oral contraceptives are especially effective, and used as the first-line of treatment to reduce acne and hirsutism, and regulate menstrual cycle. This is especially the case of adolescents.[106]

In vitro fertilization is used by some in whom other measures are not effective.[107]

Certain cosmetic procedures may also help alleviate symptoms in some cases. For example, the use of laser hair removal, electrolysis, or general waxing, plucking and shaving are all effective methods for reducing hirsutism.[35] The primary treatments for PCOS include lifestyle changes and use of medications.[108]

Goals of treatment may be considered under four categories:[citation needed]

In each of these areas, there is considerable debate as to the optimal treatment. One of the major factors underlying the debate is the lack of large-scale clinical trials comparing different treatments.

Smaller trials tend to be less reliable and hence may produce conflicting results. General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause.[109] As PCOS appears to cause significant emotional distress, appropriate support may be useful.[110]

Diet

Where PCOS is associated with being overweight or obesity, successful weight loss is the most effective method of restoring normal ovulation/menstruation. The

macronutrient-matched healthy diet.[112]

Reducing intake of food groups that cause inflammation, such as dairy, sugars and simple carbohydrates, can be beneficial.[35]

A mediterranean diet is often very effective due to its anti-inflammatory and anti-oxidative properties.[106]

dietary supplements to correct metabolic deficiencies in people with PCOS had been tested in small, uncontrolled and nonrandomized clinical trials; the resulting data are insufficient to recommend their use.[116]

Medications

Medications for PCOS include

Anti-androgens such as finasteride, flutamide, spironolactone, and bicalutamide do not show advantages over oral contraceptives, but could be an option for people who do not tolerate them.[117] Finasteride is the only oral medication for the treatment of androgenic alopecia, that is FDA approved.[35]

Metformin is a medication commonly used in

statins in the management of underlying metabolic syndrome remains unclear.[108]

It can be difficult to become pregnant with PCOS because it causes irregular

clomiphene or pulsatile leuprorelin. Evidence from randomised controlled trials suggests that in terms of live birth, metformin may be better than placebo, and metform plus clomiphene may be better than clomiphene alone, but that in both cases women may be more likely to experience gastrointestinal side effects with metformin.[128]

Infertility

Main article: Infertility in polycystic ovary syndrome

Not all people with PCOS have difficulty becoming pregnant. But some individuals with PCOS may have difficulty getting pregnant since their body does not produce the hormones necessary for regular ovulation.[129] PCOS might also increase the risk of miscarriage or premature delivery. However, it is possible to have a normal pregnancy. Including medical care and a healthy lifestyle to follow.[citation needed]

For those that do,

hyperandrogenemia, and hyperinsulinemia.[131] Like women without PCOS, women with PCOS that are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases.[132]

For overweight anovulatory women with PCOS, weight loss and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with resumption of natural ovulation.[133] Digital health interventions have been shown to be particularly effective in providing combined therapy to manage PCOS through both lifestyle changes and medication.[134]

Femara is an alternative medicine that raises FSH levels and promote the development of the follicle.[35]

For those women that after weight loss still are anovulatory or for anovulatory lean women, then

clomiphene citrate are the principal treatments used to promote ovulation.[135][136][137] Clomiphene can cause mood swings and abdominal cramping for some.[35]

Previously, the anti-diabetes medication metformin was recommended treatment for anovulation, but it appears less effective than letrozole or clomiphene.[138][139]

For women not responsive to letrozole or clomiphene and diet and lifestyle modification, there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with follicle-stimulating hormone (FSH) injections followed by in vitro fertilisation (IVF).[140]

Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "

adhesions and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function.[113]

Mental Health

Although women with PCOS are far more likely to have depression than women without, the evidence for anti-depressant use in women with PCOS remains inconclusive.[142] However, the pathophysiology of depression and mental stress during PCOS is linked to various changes including psychological changes such as high activity of pro-inflammatory markers and immune system during stress.[143]

PCOS is associated with other mental health related conditions besides depression such as anxiety, bipolar disorder, and obsessive–compulsive disorder.[33]

Hirsutism and acne

Further information: Hirsutism

When appropriate (e.g., in women of child-bearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism.[113] Progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects.[113] Metformin combined with an oral contraceptive may be more effective than either metformin or the oral contraceptive on its own.[144]

In the case of taking medication for acne, Kelly Morrow-Baez PHD, in her exposition titled Thriving with PCOS, informs that it "takes time for medications to adjust hormone levels, and once those hormone levels are adjusted, it takes more time still for pores to be unclogged of overproduced oil and for any bacterial infections under the skin to clear up before you will see discernible results." (p. 138) [35]

Other medications with anti-androgen effects include

androgenic acne
).

Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals[113]), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism, or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other medications if one does not work, but medications do not work well for all individuals.[147]

Menstrual irregularity

If fertility is not the primary aim, then menstruation can usually be regulated with a contraceptive pill.[113] The purpose of regulating menstruation, in essence, is for the patient's convenience, and perhaps their sense of well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often.[148]

If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most experts say that, if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.[149] If menstruation occurs less often or not at all, some form of progestogen replacement is recommended.[146]

Alternative medicine

A 2017 review concluded that while both myo-inositol and D-chiro-inositols may regulate menstrual cycles and improve ovulation, there is a lack of evidence regarding effects on the probability of pregnancy.

D-chiro-inositol.[155] There is insufficient evidence to support the use of acupuncture, current studies are inconclusive and there's a need for additional randomized controlled trials.[156][157]

Epidemiology

PCOS is the most common

endocrine disorder among women between the ages of 18 and 44.[22] It affects approximately 2% to 20% of this age group depending on how it is defined.[8][13] When someone is infertile due to lack of ovulation, PCOS is the most common cause and could guide to patients' diagnosis.[4] The earliest known description of what is now recognized as PCOS dates from 1721 in Italy.[158]

The prevalence of PCOS depends on the choice of diagnostic criteria. The World Health Organization estimates that it affects 116 million women worldwide as of 2010 (3.4% of women).[159] Another estimate indicates that 7% of women of reproductive age are affected.[160] Another study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of them were previously undiagnosed.[22] Prevalence also varies across countries due to lack of large-scale scientific studies; India, for example, has a purported rate of 1 in 5 women having PCOS.[161]

There are few studies that have investigated the racial differences in cardiometabolic factors in women with PCOS. There is also limited data on the racial differences in the risk of metabolic syndrome and cardiovascular disease in adolescents and young adults with PCOS.[162] The first study to comprehensively examine racial differences discovered notable racial differences in risk factors for cardiovascular disease. African American women were found to be significantly more obese, with a significantly higher prevalence of metabolic syndrome compared to white adult women with PCOS.[163] It is important for the further research of racial differences among women with PCOS, to ensure that every woman that is affected by PCOS has the available resources for management.[164][165]

Ultrasonographic findings of polycystic ovaries are found in 8–25% of women non-affected by the syndrome.[166][167][168][169] 14% women on oral contraceptives are found to have polycystic ovaries.[167] Ovarian cysts are also a common side effect of levonorgestrel-releasing intrauterine devices (IUDs).[170]

There are few studies that have investigated the racial differences in cardiometabolic factors in women with PCOS.[171]

History

The condition was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal, from whom its original name of Stein–Leventhal syndrome is taken.[90][21] Stein and Leventhal first described PCOS as an endocrine disorder in the United States, and since then, it has become recognized as one of the most common causes of oligo ovulatory infertility among women.[49]

The earliest published description of a person with what is now recognized as PCOS was in 1721 in Italy.[158] Cyst-related changes to the ovaries were described in 1844.[158]

Etymology

Other names for this syndrome include polycystic ovarian syndrome, polycystic ovary disease, functional ovarian hyperandrogenism, ovarian

eponymous last option is the original name; it is now used, if at all, only for the subset of women with all the symptoms of amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries.[90]

Most common names for this disease derive from a typical finding on medical images, called a polycystic ovary. A polycystic ovary has an abnormally large number of developing eggs visible near its surface, looking like many small cysts.[90]

Society and culture

In 2005, 4 million cases of PCOS were reported in the US, costing $4.36 billion in healthcare costs.[172] In 2016 out of the National Institute Health's research budget of $32.3 billion for that year, 0.1% was spent on PCOS research.[173] Among those aged between 14 and 44, PCOS is conservatively estimated to cost $4.37 billion per year.[23]

As opposed to women in the general population, women with PCOS experience higher rates of depression and anxiety. International guidelines and Indian guidelines suggest psychosocial factors should be considered in women with PCOS, as well as screenings for depression and anxiety.[174] Globally, this aspect has been increasingly focused on because it reflects the true impact of PCOS on the lives of patients. Research shows that PCOS adversely impacts a patient's quality of life.[174]

Public figures

A number of celebrities and public figures have spoken about their experiences with PCOS, including:

See also

  • Androgen-dependent syndromes

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Further reading

External links

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