A PRESENTATION

ON P.C.O.S

DR.CICIL ABRAHAM
VAF O02
INTRODUCTION
•Polycystic ovary syndrome (PCOS) is the most
common endocrinopathy that affects women.
•PCOS is also a leading cause of infertility.
•Women with PCOS may present with obesity,
amenorrhea, oligomenorrhea, infertility, or
androgenic features. Those with PCOS are also
at increased risk for both diabetes and diabetic
complications and cardiovascular disease.
• We know that if patients with PCOS are
screened for these diseases, many long-term
complications can be prevented .
 DEFINITION
• PCOS – Poly Cystic Ovarian Syndrome.
• Poly - denotes multiplicity, several or more
• Cystic - an abnormal sac containing gas, fluid or
semi-solid material, containing cysts.
• Ovary - one of the two reproductive glands in
the female containing germ cells or ova.
• Syndrome - a set of symptoms
• It was first described in 1935 by Stein and
Leventhal and called as Stein - Leventhal
Syndrome for many years.
 INCIDENCE
• Among the total female population: 6%
• About 50% cases seen within the age of 20 to
30 years
• 60% present with anovulation
• 90% present with hirsutism
• 80% present with Obesity
• 30% present with Infertility
 CAUSES
• The exact cause of PCOS is not known. Factors that might play a role
include:
• Excess insulin: Insulin is the hormone produced in the pancreas that
allows cells to use glucose - body's primary energy supply. If cells
become resistant to the action of insulin, then blood sugar levels can
rise and body might produce more insulin. Excess insulin might
increase androgen production, causing difficulty with ovulation.
• Low-grade inflammation: Research has shown that women with
PCOS have a type of low-grade inflammation that stimulates polycystic
ovaries to produce androgens, which can lead to heart and blood
vessel problems.
• Heredity: Research suggests that certain genes might be linked to
PCOS.
• Excess androgen: The ovaries produce abnormally high levels of
androgen, resulting in hirsutism and acne.
 PATHOGENESIS
• A complete understanding of the underlying
pathophysiology of PCOS is still lacking. Because of the
heterogeneity of this disorder, there are most likely
multiple underlying pathophysiologic mechanisms.
Several theories have been proposed to explain the
pathogenesis of PCOS.[8]
• 1) An alteration in gonadotropin-releasing hormone
secretion results in increased luteinizing hormone (LH)
secretion.
• 2) An alteration in insulin secretion and insulin action
results in hyperinsulinemia and insulin resistance.
• 3) A defect in androgen synthesis that results in
increased ovarian androgen production.
 HYPER INSULINAEMIA
• HYPER INSULINAEMIA increases GnRH pulse
frequency,L.H over F.S.H dominance,increased
ovarian androgen production,decreased
follicular maturation and decreased follicular
maturation and decreased S.H.B.G binding:all
these leads to the development of
pcos.Insulin resistance is common finding
among both normal weight and overweight
PCOS Patients.
 ANDROGEN EXCESS

• Abnormal regulation of androgen forming

enzyme(p450c17)is the main cause of excess
androgen production from ovaries and
adrenals.
 WHY
ANOVULATION
IN P.C.O.S
• Let’s review a regular menstrual
cycle.
• The menstrual cycle starts when the brain
sends LH and FSH to the ovaries. A big surge of
LH is the signal that causes the ovaries to
ovulate, or release an egg.
• The egg travels down the fallopian tube and
into the uterus. Progesterone from the ovary
causes the lining of the uterus to thicken.
• If the egg isn’t fertilized, the lining of the
uterus is shed. This is a menstrual period.
• After the menstrual period, the cycle begins
all over again.
• Now, let’s look at what happens during a
menstrual cycle with PCOS.
• With PCOS, LH levels are often high when the
menstrual cycle starts. The levels of LH are
also higher than FSH levels.
• Because the LH levels are already quite high,
there is no LH surge. Without this LH surge,
ovulation does not occur, and periods are
irregular.
• Girls with PCOS may ovulate occasionally or
not at all, so periods may be too close
together, or more commonly too far apart.
Some girls may not get a period at all.
 PROGRESSION
• PCOS is a condition that can occur at any time during a
woman’s life. Depending on when the condition occurs, it
can have varying effects.
• If PCOS occurs in an unborn baby, it can cause a small
baby syndrome.
• If PCOS develops around puberty, it can cause problems
with the start of a girl’s period.
• PCOS during adolescence and adulthood will cause
reduced periods, excess sex hormone levels, polycystic
ovaries and, in 50%, obesity.
• In ageing individuals, the features of PCOS are diabetes,
high blood pressure and abnormal blood lipid
(cholesterol) levels; the combination of these findings is
called the metabolic syndrome.
GENERALSYMPTOMS
1. Missed periods, irregular periods, or very light periods
2. Ovaries that are large or have many cysts.Ovarian volume is
increased>10 cm3.Presence of multiple (>12mm)cyst measuring
about 2-9 mm in diameter.
3. Excess body hair, including the chest, stomach, and back
(hirsutism)
4. Weight gain, especially around the belly (abdomen)
5. Acne or oily skin
6. Male-pattern baldness or thinning hair
7. Infertility
8. Small pieces of excess skin on the neck or armpits (skin tags)
9. Dark or thick skin patches on the back of the neck, in the armpits,
and under the breasts.(acanthosis nigricans).
10. Hair- an syndrome-characterized by hyper androgenism,insulin
resistance and acanthosis nigricans.
• Excessive sex hormone levels:
This is seen in the following symptoms:
• Hirsutism: excess thick pigmented body hair
following a male distribution (e.g. on the upper
lips, chin, around the nipples and on the
abdomen).
• Acne
• Male-pattern balding
• It is thought that approximately 50% of women
with PCOS have elevated androgen levels.
Infertility:
Women with PCOS have irregular menstrual cycles. They
also may not release an egg (ovulate) with each
menstrual cycle. Combined, these factors can lead to a
woman with PCOS having difficulty falling pregnant.
Obesity and insulin resistance:
Approximately 50% of women with PCOS suffer from
obesity. Obesity can also be a cause of insulin
resistance.
Type 2 diabetes mellitus:
Women with PCOS have an increased risk of developing
type 2 diabetes mellitus. There is a genetic link between
PCOS and diabetes.
Acanthosis nigricans
Hirsutism
WHY WOMEN WITH P.C.O.S HAVE
IRREGULAR PERIODS..
P.C.O.S is the main cause of ovulatory infertility.
One of the classic and key features of PCOS is
irregular or absent menstrual cycles. The primary
reason many with PCOS have irregular periods is
due to a hormonal imbalance.
• Here's how PCOS affects your menstrual
cycle: every month a follicle matures and gets
released by your ovaries to be fertilized. But
because of the hormonal imbalance seen in PCOS
(typically higher levels of androgens like
testosterone and high levels of luteinizing
hormone), the follicle doesn't mature or get
released. Instead of being released, the follicle
(often miscalled a cyst) stays in the ovaries where it
can be seen on an ultrasound. High levels of
circulating androgens such as testosterone interfere
with your menstrual cycle and can prevent
ovulation. Without ovulation and the hormonal
events that lead up to it, your uterus does not have
the stimulation it needs to shed its lining.1
• Keep in mind that this symptom can be
experienced in different ways. Some with PCOS
can have regular periods every 28 days, others
have periods every 30 to 40 days, and still, others
don't have periods at all. While this is a "normal"
symptom of PCOS, it is one that needs to be
addressed, especially if you are getting fewer
than eight or nine periods each year.
• When you don't have a regular period, not only
can it affect your fertility but it can increase your
risk of developing endometrial cancer.
 OBESITY
• PCOS is associated with overweight or
obesity,successful weight loss is probably the
most effective method of restoring normal
ovulation/menstruation,but many women find
it difficult to achieve and sustain wt loss.
 Hyper prolactinemia
• In about 20% cases,there may be mild
elevation of prolactin level due to the
increased pulsitivity of GnRH.
• Prolactin further stimulates adrenal androgen
production.
 DIAGNOSIS
• Diagnosis is based on presence of any two of
the following three criteria:rotterdam criteria-
1. Oligo\anovulation.
2. Hyper androgenism.
3. Polycystic ovaries.
Other etiologies like congenital adrenal hyper
plasia,thyroid dysfunction,hyper
prolactinemia,cushing syndrome should be
excluded.
TYPES
 1. Insulin-resistant PCOS
•
This is the most common type of PCOS. This type
of PCOS is caused by smoking, sugar, pollution
and trans fat. In this, high levels of insulin prevent
ovulation and trigger the ovaries to create
testosterone.
• If you have been that you are a diabetic on
borderline, If you have increased levels of insulin
and you are overweight, then you might be one
having insulin resistance PCOD.
 2.Pill-induced PCOS
• This type is the second most common PCOS. It
gets developed due to the birth control pills
which suppress ovulation.
• For most of the women, these effects do not last
long and they resume ovulating after the effect of
the pill is over. But some women do not resume
with ovulating for months and years even after
the effects of pills get over. During that time
women should consult the doctor.
 3.INFLAMMATORY PCOS
• In PCOS due to inflammation, ovulation is
prevented, hormones get imbalanced and
androgens are produced. Inflammation is
caused due to stress, toxins of environment
and inflammatory dietary like gluten.
 4.HIDDEN PCOS
• This is a simpler form of PCOS, once the cause
is addressed then it takes about three to four
months to get resolved.
• Causes of Hidden PCOS: Thyroid disease,
deficiency of iodine (ovaries need iodine),
vegetarian diet ( it makes you zinc deficient
and the ovaries need zinc) and artificial
sweeteners.
 COMPLICATIONS
• If not well managed, PCOS can lead to serious
long-term complications such as:
• endometrial cancer
• heart disease
• diabetes
• Hypertension
• Dyslipidemia
• miscarriage
• metabolic syndrome.
 Endometrial Cancer
• Women with PCOS do have a slightly higher chance of
developing endometrial cancer than women who don't
have PCOS.1 The more irregular and fewer periods a
woman has, the greater her risk becomes.
• During a normal menstrual cycle, the endometrium is
exposed to hormones, like estrogen, which cause the
lining to proliferate and thicken. When ovulation does
not occur, which is typical in PCOS, the lining is not
shed and is exposed to much higher amounts of
estrogen causing the endometrium to grow much
thicker than normal. This is what increases the chance
of cancer cells beginning to grow.
 Heart Disease
• Having PCOS increases a woman’s chances of
getting high blood pressure and cardiovascular
disease.2
• This is due to the high insulin levels that have
been associated with PCOS and are known to
increase one’s risk for high triglycerides,
inflammatory markers, blood pressure, and
atherosclerosis. These conditions can increase
your risk for a heart attack and stroke.
 Diabetes
• Women with PCOS frequently have insulin
resistance, meaning their body is resistant to
using glucose properly resulting in higher
glucose levels and more insulin produced.
Over time, consistently high levels of glucose
in the blood can lead to diabetes.
 Metabolic Syndrome
• Metabolic Syndrome, is a grouping of risk factors
that commonly occur together and increase one's
risk for cardiovascular disease. The most common
metabolic changes associated with this syndrome
include the following:
• Increased abdominal weight
• High levels of triglycerides.
• Low levels of good cholesterol, or HDL
• High blood pressure
• High fasting blood sugar
INVESTIGATIONS
 Investigations
• Blood tests can be used to measure the levels of FSH, LH and circulating
male hormones. The circulating male hormones that can be measured
include testosterone, but more importantly is the amount of free
testosterone.
A male hormone precursor is often raised in PCOS. This is called
dihydroepiandrosterone sulphate (DHEAS) and is one of the most
commonly elevated male hormones in PCOS. Symptoms of male hormone
excess are more important than measuring blood levels of male hormone.
• A significant number of patients with PCOS will have a reversal of the ratio
of the FSH and LH levels present in their blood. Normally FSH levels are
somewhat higher than LH. In patients with PCOS the LH levels are often
higher than the FSH levels.
• Eostrogens are group of hormones that allow women to get their
periods.In p.c.o.s,level may be normal or high.
• A sex hormone called androstenedione may be at a higher level than
normal level.
• Anti mullerian hormone-high in p.c.o.s.
• Raised fasting insulin level>25 and fasting glucose/insulin ratio<4.5
suggests I.R.
• Lipid profile.
 Ultrasound scans (USS)
• Patients with PCOS have characteristic findings when a
scan (often transvaginal) is performed of their ovaries.
• The little developing follicles usually sit under the
surface of the ovary but do not invade the centre of
the ovary.
• These follicles (which can look like block holes on
ultrasound) are usually about 6 to 10 mm in diameter
and form a ring around the surface of the ovary. A solid
white centre can be seen to the ovary. This sign is
called the pearl string sign because it looks like a string
of black pearls around a white neck.
 Laparoscopy
• Many patients with PCOS, particularly those
who are having trouble becoming pregnant
will have a laparoscopy.
• At laparoscopy PCOS ovaries look rather like
ping-pong balls. The white capsule of the
ovary is thickened and the ovary is often very
rounded.
• Bilateral Polycystic ovaries are characteristic of
p.c.o.s.
• ALSO HYSTEROSCOPY CAN BE DONE.
 Medications
• To regulate your menstrual cycle, recommend:
• Combination birth control pills. Pills that contain
estrogen and progestin decrease androgen
production and regulate estrogen. Regulating
your hormones can lower your risk of
endometrial cancer and correct abnormal
bleeding, excess hair growth and acne.
• Progestin therapy. Taking progestin for 10 to 14
days every one to two months can regulate your
periods and protect against endometrial cancer.
 FOR ANOVULATION
• Clomiphene (Clomid). This oral anti-estrogen medication is
taken during the first part of your menstrual cycle.
• Letrozole (Femara). This breast cancer treatment can work
to stimulate the ovaries.
• Metformin (Glucophage, Fortamet, others). This oral
medication for type 2 diabetes improves insulin resistance
and lowers insulin levels. If you don't become pregnant
using clomiphene, doctor might recommend adding
metformin. If you have prediabetes, metformin can also
slow the progression to type 2 diabetes and help with
weight loss.
• Gonadotropins. These hormone medications are given by
injection.
 FOR EXCESS HAIR GROWTH
• Birth control pills. These pills decrease androgen
production that can cause excessive hair growth.
• Spironolactone (Aldactone). This medication blocks
the effects of androgen on the skin. It isn't
recommended if you're pregnant or planning to
become pregnant.
• Eflornithine (Vaniqa). This cream can slow facial hair
growth in women.
• Electrolysis. A tiny needle is inserted into each hair
follicle. The needle emits a pulse of electric current to
damage and eventually destroy the follicle.
 Lifestyle and home
remedies
To help decrease the effects of PCOS, try to:
• Maintain a healthy weight. Weight loss can reduce insulin
and androgen levels and may restore ovulation. Ask your
doctor about a weight-control program, and meet regularly
with a dietitian for help in reaching weight-loss goals.
• Limit carbohydrates. Low-fat, high-carbohydrate diets might
increase insulin levels. Ask your doctor about a low-
carbohydrate diet if you have PCOS. Choose complex
carbohydrates, which raise your blood sugar levels more
slowly.
• Be active. Exercise helps lower blood sugar levels. If you
have PCOS, increasing your daily activity and participating in
a regular exercise program may treat or even prevent insulin
resistance and help you keep your weight under control and
avoid developing diabetes.
AYURVEDIC CORELATION
OF P.C.O.S