Polycystic Ovarian Syndrome (PCOS) is a prevalent hormonal disorder affecting women of reproductive age, with implications that extend beyond fertility to long-term metabolic health. A recent review in CMAJ sheds light on the latest diagnostic criteria and treatment strategies for this complex condition, aiming to assist clinicians in providing better care.

What is PCOS?

PCOS is characterized by hormonal imbalances that disrupt normal ovarian function, leading to symptoms such as irregular periods, elevated androgen levels, and metabolic complications. Diagnosis requires the presence of at least two of the following criteria:

1. Irregular Menstrual Cycles: A sign of ovulatory dysfunction.
2. Elevated Androgen Levels: Indicated by clinical symptoms like hirsutism or confirmed through blood tests.
3. Polycystic Ovarian Morphology: Identified through transvaginal ultrasound (TVUS) with specific criteria.

Why Early Diagnosis Matters

PCOS affects approximately 10% of women aged 18-39, yet it often goes undiagnosed or is identified much later. Early detection is crucial as the condition is linked to:

• Reproductive Challenges: Irregular ovulation and infertility.
• Metabolic Risks: Insulin resistance, obesity, type 2 diabetes, and cardiovascular disease.
• Psychological Effects: Increased prevalence of depression, anxiety, and body image issues.

The Underlying Causes of PCOS

PCOS arises from a complex interplay of hormonal and metabolic factors:

• Hyperandrogenism: Excessive androgen levels stimulate follicular development but prevent maturation, resulting in immature follicles.
• Hyperinsulinemia: Insulin resistance exacerbates androgen production and promotes fat deposition.
• Dysregulated GnRH Secretion: Abnormal pulsatile release of gonadotropin-releasing hormone (GnRH) disrupts the balance of luteinizing hormone (LH) and follicle-stimulating hormone (FSH).

This hormonal imbalance creates a cycle of high estrogen and androgen levels, contributing to the classical polycystic ovarian appearance on ultrasound.

Symptoms of PCOS

Women with PCOS experience a wide range of symptoms, including:

• Menstrual Irregularities: From light, irregular cycles to complete anovulation.
• Androgenic Symptoms: Hirsutism (excess facial and body hair), acne, and thinning hair.
• Obesity and Metabolic Issues: Increased BMI is common but not universal.
• Psychological Effects: Higher rates of anxiety, depression, and sleep disorders like obstructive sleep apnea (OSA).

Some symptoms, such as heavy bleeding or intermenstrual bleeding, may point to other conditions like uterine growths or infections, necessitating differential diagnosis.

Diagnostic Criteria for PCOS

The Rotterdam criteria are widely used to diagnose PCOS, requiring the exclusion of other conditions like:

• Cushing’s Syndrome: Marked by fat accumulation in the abdomen and neck.
• Thyroid Disorders: Which can mimic PCOS symptoms.
• Medication-Induced Symptoms: Some drugs may cause androgenic side effects.

TVUS findings of 20 or more follicles in an enlarged ovary (≥1 mL total volume) are indicative of PCOS, but smaller follicle counts may be normal in some women.

Approaches to Managing PCOS

Management of PCOS focuses on addressing the most troubling symptoms and mitigating long-term health risks.

1. Lifestyle Modifications

• Weight Loss: Reducing body weight by 5-10% can significantly improve symptoms such as irregular periods and hyperandrogenism.
• Diet and Exercise: Enhances insulin sensitivity and promotes hormonal balance.

2. Hormonal Treatments

• Combined Hormonal Contraceptives (CHC): Regulate cycles, reduce androgen levels, and manage hirsutism and acne.
• Progestin-Only Options: Useful for women who cannot take CHC, offering endometrial protection and regulating cycles.

3. Non-Hormonal Therapies

• Metformin: Improves insulin sensitivity, lowers androgen levels, and supports weight loss, particularly in women with a BMI over 25.
• Inositol Supplements: These over-the-counter carbohydrates from the vitamin B family can help normalize cycles and improve metabolic parameters.

4. Anti-Androgens and Cosmetic Treatments

• Anti-Androgen Medications: Address hirsutism and acne but require contraception due to potential harm to a fetus.
• Laser Hair Removal and Topical Treatments: For managing established hair growth unresponsive to medication.

5. Fertility Treatments

• Ovulation Induction: Using letrozole or metformin for women under 35.
• Advanced Interventions: Laparoscopic ovarian drilling or assisted reproduction technologies (ART) for resistant cases.

Pregnancy and PCOS

Women with PCOS face higher risks during pregnancy, including:

• Gestational Diabetes and Hypertension: Linked to insulin resistance.
• Fetal Growth Complications: Such as restricted growth or preterm delivery.

Close monitoring and weight management are essential to minimize these risks.

Long-Term Health Considerations

PCOS significantly increases the risk of chronic health issues, particularly with a BMI over 25. Long-term follow-up is recommended to monitor:

• Metabolic Health: Blood sugar, lipid levels, and blood pressure.
• Psychological Well-Being: Screening for depression and anxiety.
• Sleep Health: Early detection of OSA, which is 10 times more common in women with PCOS.

Conclusion: Early Intervention is Key

With its high prevalence and diverse impacts, PCOS demands increased awareness among clinicians and patients. Early diagnosis and tailored management strategies can alleviate symptoms, improve fertility outcomes, and reduce the long-term health risks associated with this condition.

By adopting a comprehensive approach, healthcare providers can empower women to manage PCOS effectively and improve their quality of life.

Source: https://www.news-medical.net/news/20240130/New-review-aims-to-help-clinicians-diagnose-and-manage-PCOS.aspx