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TETE A TETE WITH Dr KABERI BANERJEE ON POLYCYSTIC OVARIAN SYNDROME (PCOS)
WHAT IS PCOS?
Polycystic Ovary is a condition where there are excess androgens which is a male hormone and excess of insulin in the body. It can be genetic, inflammatory or because of lifestyle factors. Insulin resistance that is inherent in PCOS leads to excess insulin and androgens. This leads to androgenic symptoms like male symptoms like hair on the face and acne. A combination of ultrasound picture of polycystic ovaries, androgenic symptoms and menstrual irregularity is known as PCOS.
WHAT IS THE PREVALENCE OF PCOS & HOW DOES IT PRESENT WORLD WIDE?
Now 10% of the women of child bearing age are estimated to have PCOS and less than < 50% of them are properly diagnosed, so, a lot needs to be done in that field. This is the world map and you will see India as the blue area and there is severe metabolic syndrome. PCO is associated with metabolic syndrome, which means it could lead to obesity, diabetes, skin problem, so this is very much common in SouthEast Asia and pcos presence in different form in different part of the globe. We see couples and women with different ethnic origin in our clinic. South East Asia, Indian, Pakistani, Bangladeshi have increased adiposity, insulin resistance, diabetes and metabolic risks . Caucasian have the mild phenotype and the east Asians that are from Japan, Korea and China have lower BMI and milder hirsutism. Africans have higher body mass, they are more obese, their metabolic features are also high.
HOW IS PCOS DIAGNOSED? HOW HAS IT CHANGED OVER THE YEARS?
So the basic diagnosis initially used to be something we called the Rotterdam criteria, means either you have irregular periods or late periods, or you have excess androgen symptoms like balding, facial hair, pimples or acne or you have the ultrasonic picture of the PCO. If you have any two of these three you fitted into the PCOS. Now this was carrying on till the last decade till 2018 and then in 2018, there was this International evidence based guideline, where all over the world all the major bodies, the American society, the Australian society, the European society, the Centre for PCOS research and they have get together and they came to this diagnosis, that if you have irregular cycles, and if you have acne or hair on your face that is hyper-androgenism you are diagnosis is establish of PCOS, but if you do not have acne or hair and you have you blood test which is showing increased testosterone, then also you fall into that criteria. If you either have just the irregular periods or just the increased evidence of testosterone then you need to do an ultrasound which should show polycystic ovary, then you come under this diagnosis.
https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Polycystic-Ovary-Syndrome
WHAT OTHER CONDITIONS MIMIC PCOS?
Off-course there are many other causes of irregular periods like hypothyroidism, hyperprolactinemia, adrenal syndrome, hypergonadotropic hypogonadism , Cushings and Testosterone secreting tumours. Hence, proper blood work and ultrasonography must be done before confirming PCOS diagnosis.
HOW IS PCOS DIAGNOSED ?
The ultrasonic picture of PCOS with multiple cyst, that is seen on ultrasound, (usually it is not needed for young girls as many have a PCO picture which corrects over time), only in an adult group and it is done preferably with a transvaginal probe . Some studies have indicated more than 20 follicles per ovary for a diagnosis. However in the Indian context we take upto 10-15 follicles each ovary and the volume of each ovary should be more than 10 ml. Transabdominal scans are not enough for the diagnosis of PCOS.
Clinical hyperandrogenism is something like acne which is seen in this girls face it could also be less hair a frontal paucity of hair, so you have to have acne, alopecia, increased hair over your face, in and around your chest in your abdomen, so all these things they are various clinical criteria for diagnosing them and they come under the symptoms under clinical hyperandrogenism, sometimes you cannot diagnose as the clinical hyperandrogenism, then you need to do blood test, free testosterone, androgen index, bio-available testosterone, DHEA androstane are not very reliable test.
Yet another very popular blood test which is AMH gives an indication but now diagnostic. Usually the normal levels are 1-2ng/ml and anything the pcos lady do have higher levels 4 or 5 ng/ml but it cannot be used as diagnoses.
WHAT ARE THE LIFESTYLE MEASURES ONE MUST ACHIEVE WHILE MANAGING PCOS?
The most important is lifestyle measures, like correct diet and exercise. These are the main parameters in this. You have to maintain a healthy weight. You have to lose at least 5-10% of your excess weight -that much itself will cause a significant improvement in your symptoms. Weight-loss targets we all know how frustrating it can be for us and for our patients. There is a SMART way of weight loss. Specific, Measurable, Achievable, Realistic and Timely. You have to say you are 68 you become 62, specific, measurable you can measure it, achievable. You know 90kg lady you say come back in 60kg is not possible. Realistic, timely, set timelines like in 1-2 months, you have to lose this much. So the smart way of losing weight is very important and along with this your assertiveness, slow eating, cognitive behavior monitoring because you know is like a stimulus, you could be stress eating , so behavioral eating need to be in place and usually if you are <500 calories for your daily dietary intake ,so roughly for women it comes to 1200-1500 kcal is what is advised and less of whites, like sugar, less of carbohydrates, more of fruits, vegetables and proteins what is usually advised. Exercise is very important and in this if you want to lose weight moderate intensity and vigorous intensity per week moderate is 4 hrs per week and 2 hrs of vigorous in a week and muscle strengthening at least twice in a week. All your muscles, upper body, lower body, hands, legs, so it has to be regimen that a physiotherapist and a weight trainer can help.
WHAT IS THE MEDICAL MANAGEMENT OF PCOS?
The medical management which can be ovulation induction drugs, because these women do not ovulate regularly, they have early or delayed cycle., so you give medication that makes the follicle mature and release the egg called ovulation induction agents. Nowadays the first choice is letrozole. Clomiphene citrate is also a good drug, you can combine it with metformin which acts as an insulin sensitizer and reduces androgen levels in PCOS and gonadotropins. If oral drugs do not work then you give injections for stimulation and then you could go into laparoscopy and then into IUI or IVF. So, these are the drugs which cause the egg formation, correct the hormones, myoinositol which also correct the hyperandrogenism, hyperinsulinism.
WHAT IS THE ROLE OF LAPAROSCOPY IN PCOS?
I believe the young couples with suspected tubal block, endometriosis and coexisting PCO, ovaries and the duration of infertility is less than 2 years and semen analysis is normal , you do a laparoscopy and ovarian drilling. With this the androgen levels will go down, the hormonal level improves, automatic ovulation will start along with it you wash the uterus (hysteroscopy) and tubes are flushed, if there is small clots, mucus. It’s a very good fertility enhancing procedure, takes about an 1hr, it’s a keyhole surgery, good options for young patients, especially those who have not responded to medicines and do not want to go ahead with other ART methods.
WHAT IS THE ROLE OF IUI IN PCOS?
And then off course there is IUI where you give either the medications or gonadotropins, you monitor. Off course natural intercourse is good even on superpovulated cycle but if you time it specially in PCOS and wash it and inject it around the time ovulation the pregnancy rate with IUI in PCOS is definitely higher than natural. It can be tried in younger patients with good semen parameters or moderately low semen parameters.
WHEN DO WE MOVE ON TO IVF IN PCOS?
When the age of the lady is high (usually more than 35 yrs) or tubal factor or male factor, or other methods are failing and she is not responding to low dose gonadotropins, you need to give high dose and if you have to give high dose you cannot do natural or IUI because of multiple pregnancy so you do the stimulation to take out the eggs, fertilization, embryo formation and transfer. Roughly in a good center it is about 50-55% pregnancy rate per embryo transfer and cumulative 2-3 cycle close to 90%, especially in young patients. So, IVF is one of the last option but really effective in women with PCOS. Earlier we worried about OHSS in PCOS, but with the antagonist protocol and agonist trigger the incidence of OHSS is close to zero.
CONCLUSION
PCOS needs a multidisciplinary effort. Lifestyle, , fertility counseling, psychological support, nutritional counseling, metabolic intervention but finally overall the prognosis is good if lifestyle parameters are followed well and fertility potential and fertility prognosis is also very good.