Polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is a problem with hormones that happens during the reproductive years.
Polycystic ovary syndrome (PCOS) is a problem with hormones that happens during the reproductive years. With PCOS, many small sacs of fluid develop along the outer edge of the ovary. These are called cysts. The small fluid-filled cysts contain immature eggs. These are called follicles. The follicles fail to regularly release eggs.
Hormones are chemical messengers in the blood.
In PCOS, two hormones (androgens-male hormone and insulin) are responsible for the symptoms related to PCOS. If you have PCOS, you may not have periods very often. Or you may have periods that last many days. You may also have too much of a hormone called androgen- male hormone in your body. The exact cause of PCOS is unknown. However various recent studies have been done to find out the cause of PCOS.
Around one in seven girls and women have PCOS. (ASK PCOS – Evidence-based information for women with Polycystic ovary syndrome). An incidence rate of 12–18% depending on diagnostic criteria and the demographic studies (1, 2).
- Apridonidze T, Essah PA, Iuorno MJ, Nestler JE. Prevalence and characteristics of the metabolic syndrome in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005;90(4):1929–35.
- Wolf WM, Wattick RA, Kinkade ON, Olfert MD. Geographical prevalence of polycystic ovary syndrome as determined by region and race/ethnicity. Int J Environ Res Public Health 2018;15(11):2589.
What is the cause of PCOS?
Various causes have been cited in literature to explain the cause of PCOS, but to pinpoint a single cause is impossible.
- It may run in family and the woman may inherit it from either of her parents. Even males can carry the PCOS gene though the manifestations are different.
- The underlying problem with PCOS is a hormonal imbalance.
- In women with PCOS, the ovaries make more androgens (male hormone) than normal.
- Commonly seen in teenage girls and young women.
- Androgens are primarily male hormones that are produced by females too.
- Insulin resistance is a key feature of both obese & lean PCOS.
- Increased Insulin and increased androgens leads to acne, excessive androgenic hair growth, weight gain & problems with ovulation, causes weight gain & inflammation as insulin allow cells to use sugar as form of energy. This further leads to obesity, prediabetes, type 2 diabetes & heart diseases.
Studies also suggests that PCOS treatment can be precipitated by
- Stress
- irregular lifestyle (not having timely meals or sleep)
- faulty diet (eating more junk and / fried food and eating less fruits and vegetables).
- Obesity or overweight per say can also precipitate development of hormonal imbalance; excessive secretion of insulin which acts on ovaries, that in turn produces high level of male hormones called androgens.
So why is it on rise?
Where are we going wrong?
Is it our lazy, sluggish & mentally stressful lifestyle which is lack of exercise or may be wrong eating habits? And not taking enough sleep?
All these factors give rise to excess fat, especially fat around abdomen even with healthy BMI (apple shaped obesity)
Lean thin PCOS has high insulin levels. A proper diet plan with daily exercise is recommended. As muscle cells have more insulin receptors than fat cells where we can decrease insulin resistance by exercise.
What are the signs and symptoms?
Common clinical features of the condition:
- Impaired ovulation or egg development in the ovaries leading to irregular cycles and reduced fertility.
- Increased risk of weight gain, diabetes and other metabolic features
- Excess facial and body hair, acne or scalp hair loss
- Increased anxiety, depression and reduced quality of life
The symptoms of PCOS vary between women and at different life stages.
The range of symptoms individuals with PCOS may experience include:
- irregular periods
- excess hair growth on face, tummy, back
- loss of scalp hair
- acne (pimples) that may be very severe
- weight gain
- Acanthosis nigricans
- emotional challenges (depression and/or anxiety)
- increased risk of diabetes with earlier onset
- low self esteem
- poor body image
- impact on quality of life
ADOLESCENT PCOS
What is Adolescent PCOS?
Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects reproductive-aged women. While it is typically associated with adult women, it can also affect adolescents, with an estimated 20% of adolescent girls being affected.
Adolescent PCOS is defined as the presence of at least two of the following three features: irregular menstrual periods, elevated androgen levels, and polycystic ovaries on ultrasound.
One of the primary symptoms of adolescent PCOS is irregular menstrual periods. These can be infrequent or absent, making it difficult for adolescents to predict when their next period will occur. This can lead to anxiety and stress, particularly if the adolescent is sexually active and concerned about the possibility of pregnancy.
Another hallmark of PCOS is elevated levels of androgens, which are typically male hormones that are present in both men and women. In adolescent PCOS, these hormones can cause acne, excess hair growth (hirsutism), and male pattern baldness.
These physical symptoms can have a significant impact on self-esteem and body image, particularly for adolescent girls who are already vulnerable to societal pressure to conform to certain beauty standards.
How is it diagnosed?
Adolescent PCOS should be diagnosed using two main criteria*:
- irregular -menstrual cycles (relative to number of years post-menarche)
- hyperandrogenism (by examination and/or blood tests)
*After excluding other conditions that mimic PCOS.
Chart 1 Polycystic ovary syndrome diagnostic criteria in adolescence (Rosenfield)
Polycystic ovary syndrome diagnostic criteria in adolescence
Hyperandrogenism | – Evidence of clinical hyperandrogenism (moderate to severe hirsutism and/or severe acne) and/or – Evidence of biochemical hyperandrogenism |
Ovulatory dysfunction | – Irregular menstrual cycles according to time postmenarche: • 1st year postmenarche: normal pubertal transition • From 1 to 3 years postmenarche: < 21 days or > 45 days • From 3 years postmenarche: < 21 or > 35 days or < 8 cycles per year • > 1 year postmenarche: > 90 days for any cycle • Primary amenorrhea: absence of menstruation by 15 years old or > 3 years postmenarche |
Polycystic ovarian morphology | – Ought not to be used as a diagnostic criterion within this age group – Pelvic sonography should not be performed in adolescents < 8 years postmenarche. |
Metabolic factors | – Metabolic criteria are not accepted – Metabolic factors should be considered as a warning sign to look for associated comorbidities |
(Note: Menarche- Onset of periods, post menarche- after onset of periods, clinical hyperandrogenism- based on examination of patient, biochemical hyperandrogenism- diagnosed by blood tests.)
Most of the young adolescent girls wonder that how did I get PCOS?
So according to recent studies, obesity and insulin resistance are the important causative factors of PCOS. Over the past few years, the rate of obesity among adolescents has increased from 51-59% between 1987 and 1999 to 74% between 2000 and 2002. (World Health Organization (WHO). Report of the commission on ending childhood obesity). The exact causes of adolescent PCOS are not fully understood, but it is thought to be related to a combination of genetic and environmental factors.
Obesity is a known risk factor for PCOS, as is a family history of the condition. Insulin resistance, which is a common feature of obesity, may also play a role in the development of PCOS. It is important to note that obesity can increase the clinical manifestations of PCOS in adolescent girls and given that obesity plays a major role in causing PCOS, as seen in most evidence-based studies diet and appropriate lifestyle modifications can effectively help adolescent girls with PCOS and should be considered as first line treatment option.
What is the treatment of adolescent PCOS?
- A combination of lifestyle modifications and medication.
- Weight loss and increased physical activity can help to improve insulin resistance and reduce androgen levels.
- These changes help to regulate menstrual cycles and improve physical symptoms.
- Medications such as hormonal birth control can also be effective in regulating menstrual cycles and reducing androgen levels. In some cases, additional medications such as metformin may be prescribed to help improve insulin sensitivity.
- Attempting to change nutritional behaviour patterns can improve the various manifestations of the disease in these people and will also have positive effects on their quality of life and future reproductive health.
KEY POINTS TO REMEMBER:
- Adolescent PCOS is a common endocrine disorder that can have a significant impact on physical and emotional well-being.
- It is important for adolescents who experience irregular menstrual periods, excess hair growth, acne, or other symptoms of PCOS to seek medical evaluation and treatment.
- With proper management, most girls with adolescent PCOS can successfully manage their symptoms and improve their quality of life.
- Knowing adolescent girls’ perceptions and opinions about barriers and outlook to healthy nutritional behaviours is important in interventions to improve and enhance their nutritional pattern.
What do you mean by lifestyle modification?
How many of us will be happy to have irregular periods like only 3 to 4 times in a year, instead of 12? Happy right? But if it comes along with overweight or obesity or extreme thinness then I think nobody will opt for it, isn’t it? Lifestyle modification is the first line key to managing PCOS it includes modifying our day-to-day diet habits and having a daily exercise protocol according to our body composition type. In overweight or obese PCOS, weight loss of 5 to 10 % of body weight is enough to bring in changes to improve insulin resistance, hormonal balance, menstrual cycle, fertility, and the most important is the quality of life.
A healthy lifestyle includes:
- Eat a healthy balanced diet.
- Try to be active- take up a sport.
- Monitor your weight and avoid any excess weight gain, no matter what your starting weight.
- Avoid sitting for long periods by getting up to move and stretch.
- Do not indulge in addictions.
- Have a healthy support system around you.
What dietary modifications should be done?
So, let us talk about healthy nutritious diet plans.
First change is to make a small plate size of every meal. That means to decrease our meal calorie intake by 250 to 400 kcal daily.
You can start your morning with 2 glasses of warm water followed by raw vegetable juice. Many people have habit to skip breakfast in the morning, especially teenage girls do more often, which is very wrong.
Generally, our stress hormone blood levels, cortisol are higher in the morning when we wake up; by starving or skipping breakfast, can increase sugar levels, can have weight gain because of fat storage and breakdown of muscles, can suppress immune system with digestive problems & also prone for heart disease.
Vegetarian – Sprout moong chilla / nachni / ragi dosa / bhakri with sprout bhaji / cereals/ Oats/ Musli can be consumed only once a week, when it’s like no time to prepare food when you are in hurry, as that counts as a packed food.
Say NO to packed/ processed/ & frozen foods.
Non- vegetarian – good stuffed omlette with veges with a small phulka. Here you get full for next 3 hours, if you are having tea / coffee with very less sugar, & the milk has to be homemade skimmed milk.
After 3 hours – Consume a healthy fruit like an apple or pear or pomegranate or orange.
The basic idea is having low glycemic index foods with high fiber like veg, sprouted grains, fruits like apples, apricots, legumes giving enough fullness.
Avoid high glycemic foods like potatoes, corns, rice, wheat, processed sugary foods, bananas, whites like excess salt, sugar, maida white breads.
Drink lot of water, around 2 to 3 litres, always keep a full bottle of water next to your desk.
Vegetarian – Salads – sprouts, carrot, cucumber or steamed veges which is like ½ portion of plate & ½ portion with different dal preparations, you can make it with spices or tamarind or kokum but with less oil.
Here the question arises that in South East Asian countries, people only eat rice, but yet they are thin built, how? The thing is they eat boiled rice with boiled veges & we eat rice with spicy oily curries full of oil, that means trans fat.
Non – vegetarians – Chicken in grilled/tandoor/roasted form or eggs.
More ideal is eating 3 meals a day at regular interval including healthy complex carbs like whole grains, fruits, vegetables, legumes( beans, peas or lentils) & last meal c/a dinner little early around 7 – 7.30pm, after which should not eat anything c/a intermittent fasting method; where you don’t eat for 12 to 14 hours from night till morning. For this we need to eat good amount of proteins at night for
the ‘fat loss’ & to avoid ‘muscle loss’.
You can consume homemade buttermilk (from curd made out of homemade skimmed milk) in b/w as zero calories.
80% is your diet what we eat is important for weight loss so high fiber foods like flax seeds, nuts, vegetables, fruits, complex carbs, good healthy fats like fish oil or fish, avocados, almonds, walnuts. Avoid fried or frozen fish.
Along with all these healthy foods; other nutrients are also equally important like
Vit D –
- Helps in production of insulin in pancreas.
- Helps to increase follicular development to regulate menstrual cycle.
Source of Vit D – egg yolk, fish oil, mushrooms, liver, fish.
Should take weekly supplement of Vit D3.
Magnesium –
- Deficiency is commonly seen with insulin resistance.
- Help cells to absorb glucose , signals insulin production in pancreas.
- Muscle relaxants – helps in dysmenorrhea or muscle cramps, insomnia, fatigue, irregular heart beats.
- Helps in anxiety or depression.
Other nutrients like Zinc, cinnamon, chromium and green tea are also important.
Set a routine exercise protocol for about 45 – 50 mins daily.
Starting slowly with stretching exercises followed by floor exercises with an increasing count. Then you can upgrade them by doing muscle training for good posture with healthy joint protection.
Last 15 – 20 mins should be breathing exercises followed by guided meditation or shavasan to relax the whole body with mind.
And last but not the least at least 8 hours sound sleep at the right time to keep a perfect pace with our body clock as long said ‘early to bed and early to rise, makes man healthy, wealthy and wise’.
DIET IN PCOS:
The change is must. Lifestyle modification is the first key to modify our day-to-day diet habits, including a daily exercise protocol according to our body composition type.
In overweight or obese PCOS, weight loss of 5 to 10 % of body weight is enough to bring in changes to improve insulin resistance, hormonal balance, menstrual cycle, fertility, and the most important is the quality of life.
So, let us talk about healthy nutritious diet plans.
First change is to make a small plate size of every meal. That means to decrease our meal calorie intake by 250 to 400 kcal daily.
You can start your morning with 2 glasses of warm water followed by raw vegetable juice. Many people have habit to skip breakfast in the morning, especially teenage girls do more often, which is very wrong.
Generally, our stress hormone blood levels, cortisol are higher in the morning when we wake up; by starving or skipping breakfast, can increase sugar levels, can have weight gain because of fat storage and breakdown of muscles, can suppress immune system with digestive problems & also prone for heart disease.
Breakfast:
Vegetarian – Sprout moong chilla / nachni / ragi dosa / bhakri with sprout bhaji / cereals/ Oats/ Musli can be consumed only once a week, when it’s like no time to prepare food when you are in hurry, as that counts as a packed food.
Say NO to packed/ processed/ & frozen foods.
Non- vegetarian – good stuffed omlette with veges with a small phulka. Here you get full for next 3 hours, if you are having tea / coffee with very less sugar, & the milk has to be homemade skimmed milk.
After 3 hours – Consume a healthy fruit like an apple or pear or pomegranate or orange.
The basic idea is having low glycemic index foods with high fiber like veg, sprouted grains, fruits like apples, apricots, legumes giving enough fullness.
Avoid high glycemic foods like potatoes, corns, rice, wheat, processed sugary foods, bananas, whites like excess salt, sugar, maida white breads.
Drink lot of water, around 2 to 3 litres, always keep a full bottle of water next to your desk.
Lunch –
Vegetarian – Salads – sprouts, carrot, cucumber or steamed veges which is like ½ portion of plate & ½ portion with different dal preparations, you can make it with spices or tamarind or kokum but with less oil.
Here the question arises that in South East Asian countries, people only eat rice, but yet they are thin built, how? The thing is they eat boiled rice with boiled veges & we eat rice with spicy oily curries full of oil, that means trans fat.
Non – vegetarians – Chicken in grilled/tandoor/roasted form or eggs.
More ideal is eating 3 meals a day at regular interval including healthy complex carbs like whole grains, fruits, vegetables, legumes( beans, peas or lentils) & last meal c/a dinner little early around 7 – 7.30pm, after which should not eat anything c/a intermittent fasting method; where you don’t eat for 12 to 14 hours from night till morning. For this we need to eat good amount of proteins at night for
the ‘fat loss’ & to avoid ‘muscle loss’.
You can consume homemade buttermilk (from curd made out of homemade skimmed milk) in b/w as zero calories.
80% is your diet what we eat is important for weight loss so high fiber foods like flax seeds, nuts, vegetables, fruits, complex carbs, good healthy fats like fish oil or fish, avocados, almonds, walnuts. Avoid fried or frozen fish.
Along with all these healthy foods; other nutrients are also equally important like
Vit D –
- Helps in production of insulin in pancreas.
- Helps to increase follicular development to regulate menstrual cycle.
Source of Vit D – egg yolk, fish oil, mushrooms, liver, fish.
Should take weekly supplement of Vit D3.
Magnesium –
- Deficiency is commonly seen with insulin resistance.
- Help cells to absorb glucose , signals insulin production in pancreas.
- Muscle relaxants – helps in dysmenorrhea or muscle cramps, insomnia, fatigue, irregular heart beats.
- Helps in anxiety or depression.
Other nutrients like Zinc, cinnamon, chromium and green tea are also important.
Set a routine exercise protocol for about 45 – 50 mins daily.
Starting slowly with stretching exercises followed by floor exercises with an increasing count.
Then you can upgrade them by doing muscle training for good posture with healthy joint protection.
Last 15 – 20 mins should be breathing exercises followed by guided meditation or shavasan to relax the whole body with mind.
And last but not the least at least 8 hours sound sleep at the right time to keep a perfect pace with our body clock as long said ‘early to bed and early to rise, makes man healthy, wealthy and wise’.
Treatment of irregular periods
An ‘irregular’ period cycle does not have a regular monthly pattern. The most effective treatment of irregular menstrual cycles is a healthy lifestyle. For some women lifestyle plus medication may be required.
Women with PCOS are commonly prescribed the oral contraceptive pill to help regulate their periods. One of the actions of the pill is to increase levels of the sex hormone binding globulin (SHBG), which binds to the main androgen testosterone in the blood. This reduces the activity of testosterone (male hormone) and therefore reduces the symptoms related to higher levels of androgens.
No one hormonal contraceptive is optimal in PCOS. In general, lower dose preparations are advised, whilst higher dose 35mcg preparations are not recommended first line.
HIRSUTISM:
Treatment of excess hair or hirsutism
Most women with PCOS say that excess body hair (hirsutism) is very cumbersome problem to deal with because the hair growth is more over face and other body parts and can be noticed by others. The good news is that treatments for body hair have improved greatly and are increasingly easy to find and less expensive.
Cosmetic therapy
Waxing, threading, depilatory creams, plucking, laser hair removal and electrolysis can be useful ways to remove hair and reduce hair growth. Laser hair removal is now cheaper and more effective and a good option for many women. A number of laser treatments are required to reduce hair growth and results vary by hair colour, skin type and person. Red hair is more difficult (though not impossible) to remove. White and grey hair cannot be removed with laser treatment as they lack the pigment the laser needs to identify the hair follicles and destroy them. A reputable laser removal professional is important to ensure treatments are deep enough to have a lasting effect on the hair follicle.
Medical therapy
There are several medications that may help to reduce excess body hair. Examples include the contraceptive pill, and if the pill is not effective after six months adding in an anti-androgen medication. It is important to be using a form of contraception when taking anti-androgen medications.
How does PCOS cause Infertility?
- As already discussed, the hormonal imbalance in PCOS women leads to anovulation. This means that the egg does not mature properly and is also not released from the ovaries, hence not able to fertilise with the sperm and form an embryo.
- In some cases, the quality of the egg is also poor. This diminished release of egg leads to infertility and decreases chances of having a baby.
- In addition, increased body fat can also have harmful effect on the lining of the uterus and thereby failure of implantation. Weight gain, which goes hand in hand with PCOS can also affect fertility, though indirectly.
What is the treatment for PCOS and infertility?
Weight loss significantly helps in achieving results earlier with lesser dosage of drugs and injections. These women are also benefitted by antidiabetic drug called metformin. It affects the way insulin controls blood glucose (sugar) and lowers testosterone production. It also slows the growth of abnormal hair and, after a few months of use, may help return of ovulation. Use of metformin along with ovulation inducing drugs have shown better results and higher pregnancy rates.
If the above treatment modality fails to achieve ovulation than laparoscopic surgery called ovarian drilling can be done. This involves puncturing the ovary with a small needle carrying electric current to destroy small portion of the bulky polycystic ovary. This procedure carries a small risk of adhesion formation, which can however be avoided by washing the ovary with saline after the drilling. This surgery helps lower male hormone levels and ovulation. But these effects may only last a few months.