Quite many times in our daily practice we come across women who are diagnosed to have polycystic ovarian syndrome (PCOS), the incidence of which is on an increase. It affects about 8-10% of women. It’s the word ”PCOS” that catches any woman's attention, as more often than not she would have heard about PCOS from her friends/ mother or sisters. Immediate question that most of my patients ask me is “Doctor, will I be able to conceive?” and I can understand the emotion behind that question very well. Maternal instinct is paramount for any women.
While myths remain persistent in women with PCOS that they may not get pregnant, the reality is that the infertility associated with PCOS is highly treatable leading to pregnancy in most women with PCOS. The good news is that many women with PCOS will have increase in fertility just through lifestyle changes and modest weight loss. In other women pregnancy can be achieved successfully with basic infertility treatments. There will remain some women with PCOS who need additional help in conceiving which is in the form of in vitro fertilization (IVF) which is a highly effective form of treatment of infertility in women with PCOS.
Most women with PCOS often think losing weight is an almost impossible task and they question “Can diet and exercise help me conceive?” The benefits of weight reduction are much more than it seems and include improved ovulatory function, improved chances of conception, a safer pregnancy for both the mother and baby, and if the woman needs, a better response to fertility medications. I would like to reiterate the fact that by losing just 5 percent of body weight, a woman can actually restore her menstrual cycles and ovulate on her own and this fact is proven by several studies. Weight loss has also shown to reduce other symptoms such as excessive and abnormal hair growth, acne, and balding. All that a woman needs is a strong inclination and desire to help her.
Many women with PCOS feel that the reason for not ovulating is because their ovaries contain fewer eggs than normal. However the fact is women with PCOS may actually be endowed with a larger ovarian reserve at birth. The extra follicles interfere with hormonal activity and prevent a few healthy follicles from maturing and releasing. There are newer studies that have thrown an additional insight and indicate that with aging there is a natural reduction in the number of follicles which “lessens” the hormonal imbalance and thus may explain normalized menstrual cycles reported by some older women with PCOS .This may eventually lead to more cycles becoming ovulatory and an improved fertility.
Primary cause of symptoms in majority of women with PCOS is “insulin resistance” which simply means different cells in the body are either “resistant” to or are “under-responding” to the hormone insulin. Therefore, the cells do not get appropriate “signals” to perform a multitude of many tasks. In the absence of coordinated signals the entire body goes through a roller coaster of hormonal imbalance and distress, leading to an excess of male hormones which ultimately leads to weight gain, central obesity, ovulation problems, mood disorders, and skin and hair problems. The hyperinsulinaemia owing to insulin resistance promotes further weight gain creating a vicious cycle.
As a gynecologist we meet women with PCOS whose usual concerns are either cosmetic or reproductive. However, if we have far sight and look beyond, there are more serious concerns which are likely to happen beyond the reproductive age. Many studies without doubt confirm that the insulin resistance associated with PCOS can expose the women to higher risk of metabolic syndrome including hypertension; hyperlipidemia, diabetes and cardiovascular disease. By the age of 40, almost 40% women with PCOS develop pre-diabetes or diabetes! The risk of heart attack is also increased four to seven times in these women. Obstructive Sleep Apnea [OSA] and daytime somnolence (sleepiness) are found to be three times more common in PCOS patients.
Keeping in mind long term implications of PCOS, there is a need for a holistic approach to the disease process. Every responsible gynecologist should utilize every potential opportunity to evaluate and educate the patients about ways to prevent these potentially threatening long term metabolic disorders by intervening at the earliest. A long term follow up beyond reproductive age to prevent the co-morbidities and yearly blood screening for hyperlipidemia and diabetes is recommended.
Apart from the above metabolic disorders, women with PCOS are also more at risk of developing uterine, ovarian and possibly also breast cancer in later life .Chronic anovulation predisposes women to endometrial cancer and this risk is reported to be three times in PCOS women as compared to women without PCOS. These women thus should be evaluated for these conditions accordingly on a more frequent basis than non-PCOS women.
Women with PCOS should be advised to reduce their overall carbohydrate intake and in particular they should avoid sugars and refined carbohydrates, for example; white bread, white rice and anything that has been stripped of its natural fiber or made with refined white flour. These women should be encouraged to consume foods that are high in fiber, are made from whole grains, and as unprocessed as possible. They are also advised to space their meals/snacks during the day so that insulin levels do not spike. A usual advice given to PCOS women is to consume four or more small meals instead of a few large ones each day. Apart from dietary advice these women should also be encouraged to do regular moderate or vigorous exercise five or more times a week. This not only improves weight loss, regularity of menses, improved fertility but also reduces long term metabolic implications associated with PCOS.
Dr. Pooja Vaswani
Specialist, Obstetrics and Gynaecology, Brightpoint Royal Women’s Hospital, Abu Dhabi