Polycystic Ovarian Syndrome

This article has the information that i have collected during my research from various sources like Internet, books and Doctor's recommendation to one of my best friend who is undergoing the treatment for same.

What you’re about to read will give you a greater understanding of PCOS (Polycystic Ovarian Syndrome) and how to reverse its underlying condition.
This important information cannot be easily explained in a few words, so I urge you to take a few minutes and read it completely to learn definitively why and how you can finally achieve your goals of reversing PCOS, losing weight and restoring your health. Information is power when it comes to reversing a medical condition.

Introduction
Polycystic ovarian syndrome (PCOS) is a common condition occurring in 1 out of every 9 women of the reproductive age group. It is characterized by an abnormal hormone function that leads to excessive androgen production by the ovaries. This result in abnormal ovarian function and various effects on other body systems. PCOS is a heterogeneous condition with some women presenting with severe symptoms and others only having minimal complaints. This disease cannot be cured but timely management can limit its implications. Many women with mild to moderate disease are not diagnosed and thus denied the opportunity to limit the short and long-term implications of PCOS. It is therefore important for all women to be aware of this condition and to seek medical advise.

Cause and effect of PCOS
A basic understanding of the mechanism and control of ovulation is essential in order to understand the nature of PCOS.
The pituitary gland produces hormones called follicle stimulating hormone (FSH) and luteinising hormone (LH) which controls the ovulatory cycle. As the menstrual period begins, FSH stimulates the growth and development of a follicle. A midcycle rise in the LH matures the egg and leads to ovulation 24-36 hours later. This normally occurs 14 days before the onset of the next menstrual period in those women having regular menstrual cycles. The developing egg secretes oestrogen, which stimulate the lining of the womb (endometrium) to grow. The cells surrounding the follicle produce androgens in response to LH. These minimal amount of androgens are essential for normal egg development and ovulation. After ovulation, the remains of the follicle secretes progesterone, a hormone that finally prepares the womb for a possible pregnancy. If fertilisation does not occur, secretion of oestrogen and progesterone by the follicle ceases with a decline of hormonal support of the endometrium. This is followed by the onset of the menstrual period. A delicate interaction between the ovary and the pituitary gland controls the ovulatory and menstrual cycle.

Although not yet well understood, research indicates that an abnormal function of the enzymes that control the ovarian hormone production leads to PCOS. A genetic link explains the clustering of PCOS in certain families. This enzyme abnormality results in a high concentration of androgens being produced in the ovary with resulting poor egg development and absence of ovulation. This disruption of the ovarian function leads to the formation of multiple small follicles in the ovary that fail to mature and ovulate. The androgens also enter the blood circulation with the following effects on the rest of the body.

An abnormal feed back mechanism between the ovary and the pituitary gland leads to the excessive production of LH which in turn stimulates more androgen production in the ovaries initiating a vicious cycle of events.
The androgens react with receptors in the skin resulting in male pattern hair growth, acne and in severe cases even male pattern baldness.
Androgens are also converted to estrogens in fatty tissue resulting in high blood levels of oestrogens.

Resistance of various body tissues to the effect of insulin is another important factor associated with PCOS. The resistance leads to high blood levels of insulin, which together with other related substances, stimulate the production of androgens in the ovaries. The resistance to insulin is enhanced and aggravated by obesity, which thus increases the signs and symptoms of PCOS.

Symptoms of PCOS
PCOS is a heterogeneous condition with some patients complaining of minimal symptoms while others present with severe disease. The following symptoms may be indicative of PCOS and should lead to further investigations:
Menstrual irregularities are the most common symptom of PCOS. These can vary from mild irregularity of the periods, to excessive menses, to total absence of menstruation for prolonged periods of time.
PCOS is inevitably associated with infertility because of the inefficiency and/or absence of the ovulatory process. A previous pregnancy does not exclude underlying PCOS, because the expression of PCOS may have been initiated by an increase in body weight after the pregnancy.
Male pattern hair growth, acne and in severe cases male pattern baldness may be an expression of the high blood levels of androgens in patients with PCOS. These symptoms vary according to the individual sensitivity of the skin tissue to androgens. Genetic predisposition and the ethnic origin of the patient may influence this sensitivity to androgens. Women of Mediterranean origin tend to have a high skin sensitivity to androgens, whilst Asian and Scandinavian women might not have any symptoms in spite of high circulating androgen levels.
Spontaneous miscarriage occurs more commonly in patients with PCOS, most probably due to high blood levels of LH and inadequate production of progesterone to support an early pregnancy.
Obesity is a factor commonly associated with PCOS and it may aggravate the condition. It is however not a prerequisite for the diagnosis. These patients often experience difficulty in loosing weight in spite of dietary efforts.

Long term implications of PCOS
The abnormal blood lipid profile associated with PCOS as well as obesity and insulin resistance increases the risk for high blood pressure, heart vessel disease and diabetes.
High circulating oestrogen concentrations over a prolonged period of time initiate excessive stimulation and growth of the endometrium. This growth is not opposed and balanced by progesterone on a regular basis because of the absence of ovulation and thus leads to proliferative growth of the endometrium and an increased risk of endometrial cancer.
High oestrogen blood levels over a prolonged period of time may also increase the risk of developing breast cancer.
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What tests should be performed for patients with PCOS?
Any women with symptoms mentioned above should undergo a thorough assessment by a gynaecologist. Women whose mothers had PCOS should carefully watch for these symptoms and seek help if they develop any of the signs or symptoms. PCOS patients with female children should inform their children that they are at risk and watch for symptoms. Menstrual irregularity after puberty could be an early indication of PCOS and intervention at this stage could prevent excessive male pattern hair growth and acne and thus avoiding these long term cosmetic effects.
A thorough medical history and physical examination by a gynaecologist will indicate the extent of the disease and this baseline assessment is essential to monitor the response of treatment. Blood tests should be performed not only to diagnose PCOS, but also to exclude other hormonal problems that may mimic the symptoms of PCOS, like abnormal milk hormone (prolactin) production or a dysfunction of the adrenal gland. An increased LH/FSH hormone ratio as well as a raised free androgen level in the blood is suggestive and most often diagnostic of PCOS.
In the setting of the symptoms of PCOS, the diagnosis can best be confirmed by the typical appearance of the ovaries on ultrasound. This diagnosis should only be made by transvaginal ultrasonography because of the superior imaging in comparison to abdominal ultrasound.
The high incidence of insulin resistance and risk of developing frank diabetes necessitates testing of the fasting insulin and glucose level. After the menopause these women are still at increased risk of developing diabetes and heart vessel disease. Regular assessment of the blood pressure, fasting glucose and cholesterol will allow the early detection of disease and enable management that will contain progression of these problems.
Sampling of the endometrium is indicated in patients with very few or absence of menstruation in order to exclude endometrial cancer.

How should patients with PCOS be treated?
No two women suffering from PCOS are affected the same way and treatment should therefore be tailored to the symptoms and needs of the specific patient. This is only possible after a thorough assessment by a gynaecologist.

Weight loss
Weight loss should always be the cornerstone of treatment because it is associated with decreased insulin resistance and less conversion of androgens to estrogens in fatty tissue. The binding substance of androgens in the blood also increases during weight loss. which thus ensures that more androgens are bound resulting in decreased activity on the body tissues. Weight loss improves most of the symptoms of PCOS over a period of time but it should go hand in hand with a long-term effort to maintain an ideal body weight. Weight gain after a period of time will lead to the resumption of all the symptoms of PCOS. These patients should preferably seek dietary advice from a registered nutritionist because merely following one of the conventional eating programmes may not be effective and might even be potentially harmful. Traditionally a low calorie and low fat diet is advised but this should be individualized and tailored according to the patients circumstances and needs.

As Weight loss has been the major recommendation by physicians for women with PCOS. Lifestyle modifications including stress reduction, exercise, and group support, along with a decrease in total energy intake, have had positive results. A weight decrease of only 5% of total body weight is associated with decreased insulin levels, increased fertility, reduced hirsutism and acne, and lower free testosterone levels.
Women with PCOS can lower their risk of developing diabetes and heart disease by exercising and eating a healthy diet. However, some women with PCOS have trouble shedding their extra pounds. (source: Journal of the American Dietetic Association)
Sticking to a special diet is a very important aspect of PCOS care. Some women with PCOS find success by reducing their total intake of carbohydrates (cereals, breads, pastas) and choosing to eat different types of carbohydrates that are less processed (whole wheat, brown rice, beans). Replacing manufactured carbohydrate products with whole grains, fruits and vegetables can help to reduce your insulin response. The diet also should include enough protein to control the amount of sugar in the blood. (source: Hormone.org) According to many studies, women with PCOS can improve their insulin resistance just with moderate activity. Even if you exercise and don't lose weight, you are still reaping very important health benefits. Exercise has been shown to improve use of insulin and can support dietary interventions to promote weight loss; it is important that the exercise program chosen is enjoyable for the PCOS woman.
Staying as healthy as possible is the goal. The following changes can help to improve your body's response to extra insulin and can help reduce your risk of diabetes, heart disease, and stroke:
Try to stay on a healthy diet with adequate amounts of protein. Your reproductive endocrinologist or doctor should be able to suggest a healthy diet to follow.
Add whole grains, fruits, and vegetables to your diet; and - Exercise regularly to keep your weight in check.
Taking oral contraceptives and anti-androgen treatments also can help to keep your PCOS symptoms in check

Hormone treatment
If conception is not a priority, oral contraceptives are traditionally prescribed to ensure regular menstruation and prevent the long-term risk of endometrial cancer. The oral contraceptives also help to decrease the male pattern hair growth.
Where excessive hair growth and acne are predominant symptoms, anti-androgen medication can be prescribed in conjunction with the oral contraceptive. These agents ensure that the effect of the androgens on the skin is blocked. It is important to realise that the effect of the anti-androgen treatment on the skin is only evident after 4-6 months.
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Infertility treatment
Women with PCOS do not conceive because of the underlying ovulatory dysfunction. A complete assessment of the infertile couple is however essential before treatment to initiate ovulation is started. This will ensure that additional causes and factors that may contribute to the infertility are also detected and considered in the management. Only if this assessment is satisfactory, should specific treatment to initiate ovulation (ovulation induction) be undertaken. The aim of ovulation induction should be to initiate the development and maturation of a single egg in order to avoid the risk of multiple pregnancy. Ovulation induction should preferably be preceded by weight reduction because it improves the response of these women to ovulation induction.

The response of patients with PCOS to ovulation induction is unpredictable and varies from patient to patient. Uncontrolled or poorly monitored induction of ovulation can result in potentially serious complications. These include ovarian hyperstimulation syndrome and multiple pregnancy. Ovulation induction in these patients should therefore be monitored very closely by vaginal ultrasound examination and should preferably be performed by a practitioner with a special interest in the management of infertility.

Clomiphene tablets for ovulation induction are simple to use and relatively cost effective. These tablets are therefore still considered as the first line for ovulation induction in patients with PCOS. Clomiphene interacts with the brain and causes the pituitary to secrete FSH, which stimulates egg development. If egg development does not occur, the dosage of Clomiphene can be increased up to 150mg. Repeated and consecutive use of Clomiphene has a negative effect on the endometrium and it also makes the mucus around the mouth of the womb (cervical mucus) unfavourable for sperm penetration.

Gonadotrophins as the next option for ovulation induction should be considered under the following circumstances:
Poor egg development and absence of ovulation on Clomiphene.
Unfavourable effect of Clomiphene on the endometrium and the cervical mucus.
Development of multiple follicles on Clomiphene which increases the risk of multiple pregnancies.
Ovarian cyst formation on Clomiphene.

In patients with PCOS the gonadotrophin preparations which contain mostly FSH are recommended because additional LH might only compound the effect of the already high blood concentration of LH. Traditionally the low dose step up protocol with gonadotrophins is advised in order to initiate the growth of only one egg.

During this protocol half an ampoule of gonadotrophins is injected daily from day 2 of the menstrual cycle. This dosage is only increased if no egg development is evident after one week of the treatment. In some patients egg development only becomes evident after more than a week of gonadotrophin injections and thus requires patience and perseverance. This protocol limits the risk of multiple pregnancies and ovarian hyperstimulation syndrome.

In patients where ovulation induction with gonadotrophins does not lead to an egg development and ovulation, the in vitro fertilisation procedure (IVF) is ultimately indicated. Fortunately only very few patients with PCOS are resistant to ovulation induction and thus require IVF.

In selected patients with PCOS where blood tests revealed excessive androgen production from the adrenal glands, the use of corticosteroids during ovulation induction is indicated.

Surgical treatment should only be considered in severe cases that are resistant to ovulation induction as mentioned before. In the past an ovarian wedge resection was performed where a wedge of ovarian tissue was resected from each ovary. The aim of this procedure was to remove a part of the ovarian tissue that was thought to be the source of abnormal hormone production. Ovarian wedge resection leads to an improvement of the symptoms of PCOS but unfortunately requires major surgery and is associated with adhesion formation around the ovary. Both these drawbacks can be overcome by laparoscopic ovarian drilling (LOD). During this procedure the ovarian stromal tissue is destroyed by heat transmitted by a needle which is repeatedly inserted into the ovary. The ultimate result is a decrease in ovarian androgen production. LOD is a minor procedure, which enables discharge from hospital on the same day. LOD furthermore poses only a minimal risk of adhesion formation around the ovary. After LOD these patients must be monitored closely to detect spontaneous ovulation and thus time sexual intercourse appropriately.

Insulin sensitising agents
In patients where clear insulin resistance can be demonstrated on the blood tests, insulin sensitising agents like metformin can contribute to the improvement of PCOS. After a few months of treatment, some of these women start to ovulate spontaneously. Hypoglycaemia does not occur if the patients have been selected properly. These agents should therefore only be prescribed selectively after clear insulin resistance has been demonstrated. New and more specific insulin sensitising agents which may improve the above mentioned effect even further, are being developed.

Conclusion
The implications of PCOS, a common condition in the female population, can be minimised if it is recognised early, investigated thoroughly and treated appropriately. Management of infertility in these patients is more

I will be posting more information on diet and exercises soon.