PCOS | ‘Be Aware and Take Care’

Lifestyle and diseases

In 1929, Austrian psychologist Alfred Adler coined the word ‘lifestyle’ for the way a person lives. Gradually, this pattern of individual practices and personal behavioural preferences has led to rise in both, physical and mental illnesses, over a period of time.  Day to day habits that replaced physical activity with sedentary routine, shift from nutritional food to malnutrition, added up with dehydration, lack of sleep, and stress is taking its toll on health resulting in a number of ailments, now referred to as lifestyle diseases. These are preventable, chronic, non-communicable diseases that are outcome of unhealthy choices. One such endocrine disorder that affects women of reproductive age is PCOS.

What is PCOS?

PCOS – this four-lettered acronym is not as simple as it sounds. Historically, this condition is said to be there from antiquity. Earlier published description of a person with what now recognized as PCOS was from Italy and the year was 1721. However, Stein and Leventhal are considered to be the first investigators of PCOS, who presented the cases with classical signs and symptoms of PCOS in 1935. Hence, sometimes PCOS is also referred to as Stein-Leventhal Syndrome. Having known for more than eight decades, it is still being researched and understood due to its underlying complexity. PCOS is considered to be a multi-factorial disorder wherein various endocrine, metabolic, and genetic components contribute. Often, missed periods or failed conception prompts to make a visit to gynaecologist. When such a reproductive disorder turn out to be coupled with hormonal imbalance and / or metabolic disturbance, along with familial history, if any, the arising complex set of signs and symptoms is known as Polycystic Ovarian Syndrome or PCOS, in short.

Let us explore these interlinked factors; hormones, metabolism, and heredity, one by one.

The focal point of womanhood lies in one of the crucial organs of reproductive system – the ovary. Every woman have two ovaries that release one egg (at times, it could be more than one) every month, alternatively. On reaching puberty, ovaries start producing hormones; oestrogen – the female hormone and traces of testosterone – the male hormone, along with other hormones such as progesterone, anti-Mullerian hormone, and inhibin.

Hormones that run menstrual cycle

During the period from menarche to menopause, a woman’s body undergo a number of changes to be ready for possible pregnancy. Under normal conditions, recurrence of the hormone-driven events on monthly basis, 28 days on an average (ranging from 21 to 35 days), is called the Menstrual Cycle. Typically, this cycle goes through four phases; menstrual, follicular, ovulation, and luteal phases.

Menstrual phase: If egg doesn’t get fertilized, level of the hormones, oestrogen and progesterone drop, which are otherwise required during the gestation period or pregnancy. Thus the thickened lining of uterus is now no more required, and is eventually shed. As a result, blood, mucus and tissue are released from uterus through vagina as menstrual flow. Such a condition is commonly known as having Periods. The day this fluid appears is considered to be the first day (or day 1) of menstrual phase, and the next cycle begins from this day. This phase normally ranges from three to seven days with an average of five days.

Follicular phase: This phase starts with hypothalamus signalling pituitary gland to release FSH (Follicle Stimulating Hormone). As the name suggest, this hormone stimulates development of follicles on the surface of the ovaries. Each of these small sac-like structure or follicle, ranging from 5 – 20 follicles, which are at different stages of maturation contains an immature egg. While one of these egg cells is maturing, follicles begin to secrete a hormone, oestrogen (oestradiol, to be more precise) that thickens the uterine lining to prepare in anticipation of embryonic development. The follicular phase overlaps with the menstrual phase, i.e., starts from day 1 of the menstrual cycle and lasts until day 13.

Ovulation phase: Surge in the oestrogen levels during follicular phase triggers pituitary gland to secret another hormone called LH (Luteinizing Hormone). This initiates the process of ovulation or release of an ovum or egg from the follicle. Ovum released from an ovary moves through the Fallopian tube to the uterus, where it awaits fertilization by a sperm, only for a day (day 14). If remain unfertilized, it gets disintegrated in the uterus.

Luteal phase: After the ovulation has taken place, the follicle that contained the ovum or egg transforms into a corpus luteum, which starts producing two hormones; progesterone and oestrogen. At this stage there are two possibilities; either the egg gets fertilized or remains unfertilized. If the egg gets fertilized, progesterone released from the corpus luteum supports the early pregnancy period, and if it remains unfertilized, corpus letuem starts shrinking. With the regression of corpus luteum, the levels of progesterone and oestrogen also drop down. This takes place post-ovulation (day 15) until day 28, when next menstruation cycle resumes.

In short, during each menstrual cycle, an egg develops and is released from the ovaries. If egg is not fertilized, the build-up of thick lining of the uterus is shed and discharged through the menstrual fluid.  And the next menstrual cycle commences. The length of each phase of menstrual cycle differs from individual to individual and it can alter over a period of time.

Hormonal imbalance

As mentioned earlier, hormones play a decisive role at every step in the smooth running of menstrual cycle and fertility. When an ovary secrete less of oestrogen and more of testosterone, then maturation of follicles get arrested and number of such follicles become fluid-filled cysts. It results in anovulation, i.e., failure to release the ovum. Anovulatory cycles are often longer than the regular menstrual cycles. Such a disturbance could be an outcome of disruptions at any of the levels; hypothalamus, pituitary, ovary, or systemic. Such irregularity in having periods could either be prolonged, not at all, or too frequently. Hormones like LH or Insulin in excess could increase the production of testosterone or male hormone. At the onset of menstruation cycle if levels of LH are quite high, higher than FSH, then the surge for LH during ovulation fails to take place. This does not allow ovulation to occur, or causes anovulation and the periods become irregular.

Metabolism and related disorders

Insulin produced by pancreas controls sugar levels in the blood. However, due to insulin resistance that inhibits the body to exert its effect, more amounts of insulin produced to compensate the requirement. Thus high level of insulin causes ovaries to produce more of testosterone in the body, Apart from causing anovulation it also lead to weight gain. This worsens the condition as presence of more fat induces the pancreas to produce more insulin.

Genetics and PCOS

PCOS is at times found to be running in families, where grandmother, mother, or sister if had suffered from this condition, then chances of developing it increases. This establishes genetic link to PCOS.

In short, PCOS is interplay of endocrine, metabolic, and sometimes genetic factors.

Symptoms

PCOS is a Syndrome, which means there are a number of symptoms associated with this condition. Three characteristic features are: multiple cysts in ovaries, excess male hormones, and irregular periods. Though signs and symptoms vary with an individual, but obesity makes it more severe in nature.

Due to hormonal imbalance, number of cysts appears in ovaries that cause the typical symptoms to appear. These multiple cysts are seen as string of pearls in ultrasound

First and foremost one experiences irregularity of menstrual cycle; delayed or missed periods

Increased levels of androgens (male hormones) may result in hirsutism (excess hair growth on unexpected places), oily skin with acne, and male pattern baldness or hair loss from the scalp

Weight gain, especially around the waist, due to insulin resistance leading to higher levels of insulin in the body

Diagnosis

It would be better to visit a gynaecologist well-prepared, with complete details of the signs and symptoms experienced, no matter how insignificant those seem to be. Do make a mention of familial history of PCOS, if any. These would provide a clue while deciding upon the diagnostic approach. In any case, physical examination, blood profiles and an ultrasound would be the basic tools to identify the underlying causes, to a certain extent.

Treatment

PCOS cannot be cured but yes, can be treated to ease out the symptoms. Timely medical intervention and proper follow up can put a check on the development of further complications.

Taking Care

PCOS often start developing around puberty. If not taken care of, it could result in long-term complications with advancing age, which includes;

• Infertility
• Type2 Diabetes, Gestational diabetes
• Metabolic disturbances like high blood pressure, high blood sugar, abnormal cholesterol or triglycerhide levels thereby increasing chances of heart-related ailments
• Depression, anxiety, sleep and eating disorders
• Abnormal uterine bleeding
• Uterine lining (endometrium) cancer

Since PCOS is a lifestyle disease, introspection would tell what changes in the lifestyle are warranted. A good nutrition, balanced diet, regular exercise clubbed with physical activity could possibly make a turnaround in the life.

This information on PCOS is not an exhaustive one, and it can’t be due to its complex nature. But the bottom line is – to be aware and take care. Be proud of womanhood.