Is PCOS just a scan where the report says that you have cysts in your ovary?
The answer is NO.
An ultrasound report never diagnoses PCOS. A polycystic ovarian syndrome is characterized by:
- Anovulation– The ovaries do not release an egg monthly as they would in normally ovulating women.
- Hyperandrogenemia– The levels of male hormone levels like testosterone are increased in the blood leading to certain clinical symptoms like acne, male pattern hair loss(alopecia), or increased thick hair growth in a male pattern(hirsutism).
- Insulin resistance– Levels of insulin, the hormone which reduces blood sugar in the blood are increased, but the cells become resistant to its action.
What are the tiny cysts seen on an ultrasound in PCOS?
During a normal ovulatory cycle, there will be one dominant follicle that forms and releases an egg around day 14 of our cycle. If there is no pregnancy in that cycle, this resolves, and a new cycle starts.
In PCOS, due to hormonal imbalance, multiple follicles start developing, but they do not grow beyond a particular stage, and the growth gets arrested in-between. There is no release of an egg happening, and these immature follicles appear like minute fluid containing cysts in the ovary on ultrasound.
These are not actual cysts that need to be surgically removed, nor can they be dissolved with medication.
The symptoms of PCOS
- Irregular periods- 60 to 80% of cases
- Cystic acne
- Hirsutism– Excessive thigh hair growth in areas like the upper lip, face, chest, upper back, etc.
- Alopecia– Frontal balding
- Subfertility– Difficulty or delay in getting pregnant due to lack of ovulation (anovulation)
- Obesity– Seen concomitantly in about 50% of cases though it is not the effect but rather an aggravating factor.
On examination by the doctor, patients may have:
- Increased BMI
- Increased waist-hip ratio-due to increased incidence of abdominal obesity
- Acanthosis Nigerians-dark, velvety patches of skin over the neck or axilla
Investigations for PCOS
There are many investigations performed in PCOS. It usually starts with a complete clinical history and physical examination of the patient. The investigations asked for maybe few or all of the following depending on the patient history:
- 75-gram oral glucose tolerance test
- Lipid profile
- Fasting insulin
- Day 2 or 3 FSH, LH
- Free testosterone
- TSH and serum prolactin-to rule out other causes of irregular periods
- Ultrasound pelvis-imaging of the uterus and ovaries. The ovarian volume should be more than 12 cc, and the number of small follicles should be more than 20 per ovary to report the PCO appearance of ovaries. Sadly it is often over-diagnosed on ultrasound, alarming the patients unnecessarily.
- In fact, the latest guidelines suggest that ultrasound is not required to diagnose PCOS in the adolescent age group.
The magic treatment for PCOS
Though a complete answer requires a multi-faceted approach, there is one most straightforward magical treatment which will apply across all age groups for the treatment of PCOS and that is WEIGHT LOSS. It has been proven that losing even 7 to 10% of our weight can bring about a beneficial effect on our hormonal profile and improve cycle irregularity. There is no magic pill for PCOS; we only need to be more proactive in leading a healthy life.
Treatment of PCOS in adolescence:
‘Catch them young.’ This phrase applies to preventive health. In the absence of clean eating habits and lack of physical activity, I see many youngsters in their teens and twenties weighing 80 to 100 kg. This age group doesn’t need too many medicines; weight loss should be the most prescribed treatment. JUST GET THEM TO MOVE for at least 45 min a day, six days a week. This could include any activity like running, cycling, swimming, aerobics, Zumba, dance, yoga, etc. and the list is endless.
In case acne or hirsutism is a significant concern, then the application of creams, oral antiandrogens, and hair removal methods are prescribed.
In case heavy bleeding with irregular periods is a concern, then low dose contraceptive pills are prescribed for cycle regulation as well as improving the hormonal profile.
The thing which we do not need to worry about or give importance to here is the polycystic appearance of ovaries on ultrasound, and in fact, the current guidelines state that adolescents don’t need an ultrasound.
Treatment of PCOS in women of childbearing age group:
The main concern in this age group is controlling irregular periods and getting pregnant and that too as quickly as possible which will be the patient’s wish.
The first thing patients need to realize that pregnancy is possible but that they need to lose weight to speed up the time taken to pregnancy.
The primary pathology of PCOS is anovulation, where an egg doesn’t get released each month as should usually happen.
Hence, after a complete history and physical examination of a couple, oral medicines or gonadotropin injections are given to the patient to stimulate the ovaries to produce eggs. The response is generally monitored using a series of scans called follicular study to assess whether a dominant follicle is forming and releasing the egg in response to our medicines.
Where hyperinsulinemia is a concern or where standard ovulation induction fails, insulin sensitizers like metformin or myoinositol are added to help get a better response.
Treatment of PCOS in the perimenopausal age group:
You may think that once you have completed your family, you do not need to be bothered any longer about irregular cycles as long as they are not too heavy.
But this is where you will be wrong, as the underlying pathology in PCOS persists beyond childbearing and can predispose you to the metabolic syndrome which is a combination of:
And all this, in turn, predispose to endometrial hyperplasia (thickening of the inner lining of the uterus), which in turn, if left unchecked over a long time, can lead to endometrial cancer.
Hence, we need to continue our annual gynec examinations and adopt a healthy lifestyle to prevent many of the comorbid medical conditions outlined above.
Endometrial sampling by a probet biopsy may be required where there is a suspicion of endometrial hyperplasia. And if this is detected, it will need to be treated with cyclical progesterone therapy or Mirena Intrauterine device insertion to reverse the hyperplastic changes.
Diet in PCOS
Among the many mind-boggling diet varieties that everyone follows nowadays like paleo, keto, Atkins, drinking herbal supplements, seven-day diet, and intermittent fasting, it’s quite challenging to know which diet should be followed for PCOS. Here are a few tips for you:
- Think global but eat local: If you are a rice eater, eat rice. If you are a North Indian, take rotis.
- Eat-in moderation: Take a balanced plate of 50% carbohydrate (rice, idli, dosa or roti), 35% vegetables, dal, sambar or egg and 25% curd, papad, salad or pickles
- No one food group is a villain: No food, not even all fats are bad for health. Hence, it is not necessary to cut them out completely
- Avoid eating out more than once or twice in a week, and that includes taking away or ordering in also
- It may be sensible to take a cup of rice as a measure and divide it for your sambar, rasam, etc. as otherwise, we may consume larger quantities unknowingly.
- Eat only when you are hungry, not when you are bored, sad, depressed, watching TV or simply because it is available
- Never do grocery shopping when hungry as we often tend to make unhealthy choices.
- Drink plenty of water, tender coconut, buttermilk, etc.
- Include whole grains, fresh fruits, and vegetables, nuts, ghee, eggs, fish, oils like coconut, sesame, or groundnut in your diet.
- Avoid eating anything processed or basically comes ready to eat in a packet like Maida, sugar in its different avatars, refined oils, cookies and biscuits, all soft drinks and colas and fruit drinks.