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Definition/Description

Polycystic Ovarian Syndrome (PCOS), formerly known as Stien-Leventhal Syndrome, is a disorder affecting the hormones of women of child bearing age.  Ovaries are enlarged secondary to multiple cyst formations within the ovaries.

PCOS has also been associated with features of metabolic syndrome which include insulin resistance and diabetes mellitus as well as cardiovascular factors such as dyslipidemia. Causative factors seem to be unknown but there are certain predispositions which are strongly correlated with the incidence of PCOS. Insulin resistance and compensatory hyperinsulinemia are said to be significant causes for hyperandrogenism in women with PCOS. Furthermore, obesity worsens these hormonal imbalances thus making the clinical features evident – it has been observed that women with PCOS who are obese have a higher incidence of menstrual irregularities and hirsutism compared to non obese women with PCOS^[1].

Prevalence

PCOS affects 4-12% of childbearing aged women^[2] It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age. ^[3]

• 50% of these women have amenorrhea^[4]
• 30% of these women have abnormal menstrual bleeding^[4]
• 60% of these women are obese^[5]
• 40% of women with PCOS have associated insulin resistance and type 2 diabetes mellitus^[4]

Pathophysiology

PCOS is believed to be a genetically inherited metabolic and gynecological disorder.  A repetitive vicious cycle occurs with hormones resulting in the progression of PCOS. To begin with, failure of an ovary to release an oocyte results in increased levels of androgen production/release from the ovaries as well as the adrenal cortex. Excess androgens have a twofold effect. First, androgens are stored in adipose tissue where they are then converted into estrogen. Excess androgens then result in an increased production of Sex Hormone Binding Globulin (SHGB). This increased SHGB then has the consequence of an even greater fabrication of androgens and estrogens. Thus the cycle begins. The cause of the excess androgen production has been correlated to surplus Luteinizing hormone (LH) stimulation resulting in the presence of cystic changes in the ovaries.^[6]

Characteristics/Clinical Presentation

Signs and symptoms of PCOS include the following: 

• Enlarged polycystic ovaries^[6]
• Obesity and central fat distribution^[6]
• Hirsutism – male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs ^[6]
• Virilization – development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass, and clitoromegaly^[6]
• Anovulation – failure of the ovaries to release an oocyte^[6]
• Amenorrhea – absence of a menstrual period in women of childbearing age^[6]
• Oligomenorrhea – presence of menstrual cycles greater than 35 days apart^[6]
• Dysfunctional uterine bleeding^[7]
• Acne related to hyperandrogenism^[8]
• Infertility; recurrent first trimester miscarriages^[2]
• Obstructive Sleep Apnea

Associated Co-morbidities

• Type 2 Diabetes Mellitus^[5]
• Obesity^[5]
• Cardiovascular disease^[5]
• Hypertension^[5]
• Ovarian cancer^[5]
• Breast cancer^[5]
• Endometrial cancer^[5]

Diagnosis

There is no single specific test which can be used to accurately diagnose PCOS. Rather a comprehensive examination needs to be carried out by a clinician which involves a detailed history, physical examination and investigative procedures. Clinicians should focus on taking a detailed menstrual history for any irregularities, any significant change in the patient’s weight and physical appearance (acne, alopecia, terminal hair, acanthuses nigricans, skin tags)^[9]

Investigations which could help arrive on a definite diagnosis include:

Ultrasound – An ultrasonic test allows visualization of any cysts which may be present on the ovaries or if there is any enlargement of one or both ovaries. A transvaginal ultrasound which involves inserting the probe into the vagina is usually done for women who have been sexually active. For women who are not sexually active, an abdominal ultrasound is opted for where the ovaries are viewed from outside the abdominal wall however, a clearer picture is obtained transvaginally compared to a transabdominal ultrasound^[10].

Hormonal Blood Tests^[10]

1. Hyperandrogenism – Testing for androgen levels and free androgen index (FAI) are best for diagnosis hyperandrogenism which is a key finding in women with PCOS.
2. Tests to detect female hormonal levels – Estradiol, Follicle Stimulating Hormone, Luteinizing Hormone levels.
3. Tests to exclude other conditions which could present as PCOS – Thyroid Stimulating Hormone, Prolactin, Adrenal hormones.

Criteria for Diagnosis

A conclusive diagnosis for PCOS can be made if at least 2 out of 3 of the following is found criteria are met^[10]:

1. Polycystic ovaries – 12 or more follicles are seen on one ovary or the size of one or both ovaries have enlarged.
2. Hyperandrogenism – high levels of androgenous hormones or male pattern of hair growth.
3. Menstrual Abnormalities – lack of menses or menstrual cycle irregularities or anovulation.

Medical Management

Medical management is completed through medications or surgical removal of the ovarian cysts/hysterectomy. Medications can be used to shrink ovarian cysts through control of the mentrual cycle and subsiding release of excess luteinizing hormone thus preventing the overproduction of testosterone.^[2]

Medications

Treatment for infertility may include the following for inducing ovulation:

Treatment for those not interested in conceiving a child may include:

Cystectomy

Physical Therapy Management

Exercise training has shown great improvement in 50% of the women diagnosed with PCOS, by targeting the menstrual irregularities and promoting ovulation. Weight reduction is an important component of the physical therapy program since weight reduction improves glucose intolerance which in turn could resolve the reproductive and metabolic derangements often associated with PCOS. Weight loss may also reduce the pulse amplitude of luteinizing hormone thus reducing androgen production^[1].

Physical therapists should also be aware of the clinical presentation of PCOS.  Women with PCOS may experience low back pain, sacral pain, and lower quadrant abdominal pain.  However, a thorough patient history can provide information of a gynecologic/metabolic connection.  Concern of possible presence of PCOS requires immediate referral to a physician.^[4]

In treating patients with a PMH of PCOS for a non-related condition, be aware of related medical concerns that may affect the patient’s ability to participate in activities including glucose intolerance and insulin resistance.^[4]

Side effects of medications need to also be taken into account.  For example, the side effects of clomiphene citrate, an ovulation inducer, includes insomnia, nausea/vomiting, blurry vision, and frequent urination.^[4]

Lifestyle Changes

Recommendations:

• Weight loss – Cornerstone in controlling all derangements seen in PCOS^[8]
• Regular exercise (30min/day) lowering insulin levels – walking/jogging^[8]
• Dietary Modifications – Reduction of carbohydrates consumed to reduce insulin levels^[8]

Differential Diagnosis

Resources

Case Report: PCOS Psychosocial Well-Being, and Sexual
Satisfaction in Women with Polycystic Ovary Syndrome

Health related Quality of Life in PCOS

Commentary: Promising clinical practices of metformin in women with PCOS and
early-stage endometrial cancer

References

1. ↑ ^1.01.1 Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. ↑ 2.00^{2.012.022.032.042.052.062.072.082.092.10} Sheehan MT. Polycystic ovarian syndrome: diagnosis & management. Clinical Medicine & Research 2004;2:13-27.
2. ↑ Harrison CL, Lombard CB, Moran LJ, Teede HJ. ↑ 4.0^{4.14.24.34.44.5} Goodman CC, Fuller KS, editors. Pathology: implications for the physical therapist. 3rd ed. St Louis: Saunders Elsevier, 2009.
3. ↑ ^{5.05.15.25.35.45.55.65.7} Daniilidis A, Dina K. Long term health consequesnces of polycystic ovarian syndrome: a review analysis. Hippokratia 2009; 13:90-92.
4. ↑ ^{6.006.016.026.036.046.056.066.076.086.096.106.11} Callahan TL, Caughey AB, editors. Blueprints: obstetrics & gynecology. 5th ed. Baltimore: Lippincott Williams & Wilkins, 2009.
5. ↑ Futterweit W, Diamanti-Kandarakis E, Azziz R↑ 8.0^{8.18.28.38.48.5} Merck manual of medical information. 2nd ed. New York: Merck & Co., Inc, 2003. p 1234-35.
6. ↑ Williams T, Mortada R, Porter S. ↑ 10.0^10.110.2 Jean Hailes: How is PCOS diagnosed? Available from: function gtElInit() { var lib = new google.translate.TranslateService(); lib.setCheckVisibility(false); lib.translatePage('en', 'pt', function (progress, done, error) { if (progress == 100 || done || error) { document.getElementById("gt-dt-spinner").style.display = "none"; } }); }