PCOS- INTRODUCTION

PCOS is a common endocrine disorder causing infertility that occurs in 3-10% of reproductive-aged women. The precise cause of PCOS is not known. However, PCOS leads to an inability of follicles in the ovary to produce and release mature eggs. This results in polycystic ovaries (i.e., ovaries with many small follicles or cysts), infertility, and hormonal imbalances.

Clinical symptoms of PCOS include: (1) menstrual irregularities, (2) inability to get pregnant due to lack of ovulation, (3) increased hair growth in a male distribution pattern (e.g., on face and chest), (4) acne, and (5) obesity. Other problems associated with PCOS include: increased miscarriage rates and long-term health problems --  including diabetes, dyslipidemias (high cholesterol and triglycerides), uterine cancer, and cardiovascular disease. If diagnosed properly, several treatment options are available that can lead to positive reproductive outcomes and that will mitigate many of the other long-term health effects of PCOS.

PCOS- DEFINITION

PCOS is defined as the presence of (1) chronic anovulation and (2) hyperandrogenism.
Chronic anovulation means that a woman is not ovulating, or releasing an egg, monthly. This typically leads to "missed" or "skipped" periods. Women with PCOS usually have less than eight menstrual cycles per year, and it is not uncommon to skip periods entirely. Anovulation can be caused by chronic hormone abnormalities – including pituitary signaling hormones [e.g., follicle stimulating hormone (FSH) and luteinizing hormone (LH)], excess estrogen, decreased progesterone, increased androgens, and insulin resistance.

Hyperandrogenism seen in PCOS is an excess of "male" hormones (androgens) such as testosterone and androstenedione. Increased androgens can be detected by elevated levels in the blood, or by clinical manifestations of PCOS that include hirsutism and/or acne. Hirsutism is defined as increased hair growth in a typical "male distribution" pattern (e.g., upper lip, chin, chest, lower abdomen and/or inner thigh).

PCOS should be diagnosed only after ruling out other potential causes of anovulation and/or hyperandrogenism . Secondary causes include hyperprolactinemia (elevated blood prolactin levels), thyroid dysfunction, and adrenal disorders.

PCOS - Treatment

PCOS- Menstrual Irregularities
Anovulation can lead to an abnormal overgrowth of the uterine lining (endometrial hyperplasia)increasing the risk of uterine cancer. Menstrual abnormalities can be treated with cyclicprogestins or oral contraceptives. It is recommended that treatment allows for shedding of the uterine lining at least every three months.

PCOS Hyperandrogenism/Hirsutism
The goal of PCOS treatment is to decrease the amount of androgens in the bloodstream, thereby decreasing the clinical effects of androgens on the body (e.g., hair growth and acne). The most common treatment is low-dose oral contraceptives. Oral contraceptives decrease androgens in a variety of ways - including suppression of gonadotropin secretion with subsequent reduction in ovarian androgen secretion, and increased sex hormone binding globulin (SHBG) synthesis, which binds the androgens. For hirsutism, it is recommended to combine medical treatment with mechanical hair removal methods such as electrolysis, waxing, or laser hair removal.

Metformin for PCOS should be given in doses of 1,500-2,000 mg per day divided into two to three daily doses. Renal and liver function should be assessed prior to starting the medication and monitored annually. Patients should be encouraged to maintain a healthy diet and exercise to improve the long-term effects of therapy.