Polycystic Ovarian Syndrome

PCOS, also known as Stein Leventhal syndrome, is an endocrine(hormonal disorder) that affects 5-10% of females, with variation among races and ethnicities.
This syndrome can be diagnosed if at least 2 of the following conditions are present:

- Oligomenorrhea *or amenorrhea *

-hyperandrogenism* and

-polycystic ovaries on ultrasound.

Laboratory testing often reveals mildly elevated serum androgen (such as testosterone etc) levels, an increased ratio of luteinizing hormone to follicle stimulating hormone (LH:FSH), lipid abnormalities and insulin resistance.

PCOS is a constellation of problems. The body's endocrine system is all about checks, balances, and feedback. When one hormone is secreted abnormally, like a domino effect, other systems in the body are negatively affected.




Gonadotropin Releasing hormone (GnRH) is released by the hypothalamus ( ) in a pulsatile manner which causes the release of LH and FSH from the pituitary gland. In PCOS, there is an abnormal release of GnRH, causing LH to be released more than FSH in an erratic fashion. LH stimulates the ovaries to produce androgens (testosterone). Couple this with the lower levels of FSH, whose job is normally to stimulate the ovaries to take those androgens and convert it to the potent form of estrogen called estradiol, you now have a state in which there are too much androgens in the body (hyperandrogenism).

These increased androgens cause the follicles in the ovaries to shrink and also contribute to abnormalities in the lipid metabolism and distribution in the body as well as the development of acne and hursuitism- defined as the presence of coarse, dark, terminal hairs distributed in a male pattern, seen most commonly on the upper lip, chin, sideburns, chest and the midline of the lower abdomen.





Now, even though there is decreased estradiol, fat cells in the periphery of the body can take those androgens and convert them to another form of estrogen called estrone. This constantly feeds back to the hypothalamus and pituitary gland (as opposed to cyclically) and causes problems there. That estrone also continuously stimulates the lining of your uterus, leading to endometrial hyperplasia, which can predisopse you to endometrial cancer and other health problems in the future.

Another problem with PCOS is the issue of insulin resistance. Insulin is the hormone that allows glucose to get into the body's cells. Insulin resistance is defined as a reduced glucose response to a given amount of insulin. The mechanism of this decreased sensitivity to insulin appears to be due to an abnormality in one of the insulin receptors. Both lean and obese women with PCOS are found to be more insulin resistant than non-PCOS counterparts of the same weight.

Insulin resistance has been associated with an increase in several disorders including type 2 diabetes mellitus, hypertension, dyslipidemia*, and cardiovascular disease. Therefore, PCOS is not simply a disorder of short-term consequences such as irregular periods and hirsutism, but also one of long-term heath consequences

Short-term consequences
1. Irregular menses
2. Hirsutism/acne/androgenic alopecia
3. Infertility
4. Obesity
5. Metabolic disturbances
6. Abnormal lipid levels/glucose intolerance

Long-term consequences
1. Diabetes mellitus
2. Cardiovascular disease
3. Endometrial cancer

During a normal menstrual cycle, the various hormones listed go through cycles - rising and falling at certain times. In PCOS however, they tend to remain at a constant level throughout the cycle.

A follicle swells but does not release an egg, so it becomes a cyst. The cells surrounding the cyst release weak levels of testosterone, which the body converts into estrogen ( in the form of estrone). The brain senses the high levels of estrogen present and therefore assumes that the ovaries are functioning normally and a ripe egg is ready to be released. The secretion of FSH is cut back and the LH is sent out. LH usually triggers the ripened egg to break away ready for impregnation, but as there is in fact no egg, the follicle forms a cyst and the process is repeated cycle after cycle and the problem gets worse.

In short - polycystic ovaries are where follicles have matured in the ovaries but are never released due to abnormal hormone balance.
What are the symptoms?

Each woman with PCOS will have varying symptoms and though there is a particular set of dignostic symptoms, each case should be looked at separately.

Some of the symptoms are:
-Acne
-Irregular or absent periods
-Numerous cysts on the ovaries
-Hirsutism
-Obesity
-Infertility or reduced fertility
-Hair loss (androgenic alopecia - similar to male pattern baldness)
-High Blood Pressure
-Elevated Insulin levels, diabetes or insulin resistance.

There are some techniques that your doctor can employ to keep this chronic disease under control. PCOS has been shown to be amenable to ovulation inducing drugs (such as Clomiphene), for patients that want to become pregnant, as well as diabetic medications (such as Metformin).

Since women with PCOS can present with a number of combinations of symptoms, it is important to be patient with your physician since most of these symptoms could be independant or part of many other conditions. However, if you feel as though your symptoms could be explained by PCOS, encourage your doctor to investigate it further and at least attempt to rule it out.

Be an advocate for your health. Knowing is the first step.

* Oligomenorrhea is the medical term for infrequent uterine bleeding episodes with intervals of more than 35 days

*Amenorrhea is the absence of a menstrual period in a woman of reproductive age

*Hyperandrogenism is a medical condition characterized by excessive production and/or secretion of androgens

Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 17. Polycystic Ovarian Syndrome and Hyperandrogenism" (Chapter). Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG: Williams Gynecology: http://www.accessmedicine.com/content.aspx?aID=3157034.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=3157034&citeType=1>

Tzadik Mor, Purcell Karen, Wheeler James E, "Chapter 40. Benign Disorders of the Ovaries & Oviducts" (Chapter). DeCherney AH, Nathan L: CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10th Edition: http://www.accessmedicine.com/content.aspx?aID=2389603.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=2389603&citeType=1>