Polycystic ovary syndrome: What do we know, or think we know?

The management of polycystic ovary syndrome usually spans a woman's reproductive years. While the treatment of symptoms is of primary concern, given its long-term nature, the benefits and potential risks need to be assessed and balanced. The variability of presentation coupled with the phenotypic diversity of this patient population, requires the individualisation of treatment to each patient. Periodically the regime has to be modified owing to a possible desire for pregnancy.

Defining the polycystic ovary

17 - 33% of the "normal" population have polycystic ovaries. In the Volunteer Study of Women's Health 224 female volunteers, aged 17 - 25 years, were evaluated with the following findings:

• 33% had polycystic ovaries;
  
• 80% with polycystic ovaries had at least one feature of PCOS;
  
• 20 % with polycystic ovaries were "normal";
  
• 75% with normal ovaries had symptoms attributable to PCOS.

What is therefore the difference between women with polycystic ovaries only and with polycystic ovary syndrome? The answer is that the presence of polycystic ovaries only represents a milder end of the PCOS spectrum.

Diagnosis of exclusion

PCOS will always remain a diagnosis of exclusion until such time in the future when a "simple blood test" will be available to make the diagnosis of PCOS with 100% accuracy. This is however, just a pipe dream for now.

Disorders with a similar clinical presentation include:

• Congenital adrenal Hyperplasia;
  
• Cushing's Syndrome;
  
• Androgen secreting tumours;
  
• High doses of exogenous androgens.

Before the diagnosis of PCOS is made, meticulous care should be taken to exclude the above mentioned related disorders.

Quality of life in women with PCOS

As clinicians, dealing with this common metabolic disorder, we sometimes tend to neglect the psychological aspect of "poor self esteem" in patients with PCOS. This is due to hirsutism, acne, menstrual irregularity, infertility and worst of all, obesity. Lack of support from the clinician and guidance as to how to cope, can lead to bigger and longer lasting psychological issues. Referring these patients to, and encouraging them to become part of PCOS support groups, is therefore essential.

Long-term health risks of PCOS

Long-term health risks include the development of endometrial cancer, cardiovascular disease with dyslipidaemia and diabetes mellitus. It is especially the true PCO patient, with a family history of type 2 diabetes, has an eight-fold risk of developing diabetes mellitus.

Where do insulin sensitizing and lowering drugs fit in?

Women with polycystic ovaries are more insulin resistant than weight - matched women with normal ovaries. Insulin resistance is seen in10% of slim, and 40% of obese women with PCOS. It is also associated with reproductive abnormalities. Improving insulin sensitivity through weight loss and lifestyle first and foremost, can ameliorate these symptoms. Pharmacological intervention should be considered only once weight loss and lifestyle changes have failed.

Insulin resistance can be measured by a number of expensive and complex tests but in clinical practice it is not necessary to measure it routinely. This is due to the fact that there is normal physiologic fluctuation in insulin levels and the lack of a standardized universal insulin assay, which ultimately leads to over diagnosis and unnecessary treatment with insulin sensitizing agents. It is more important to check impaired glucose tolerance with a fasting GTT.

Simple screening tests include an assessment of body mass index and waist circumference.

A Cochrane review concluded that the benefit of using therapy to lower insulin levels, such as metformin, is limited in terms of improvement in reproductive outcome and metabolic parameters. In particular, the use of metformin, either alone or in combination with drugs to induce ovulation, did not increase the chance of having a live birth. Furthermore, despite evidence of a reduction in development of diabetes in a high risk non - PCOS population, the long term use of metformin in reducing the risk of developing metabolic syndrome is questionable. Lifestyle advice, with appropriate attention to diet and exercise, has to be the mainstay for young women with PCOS.

Laparoscopic ovarian surgery - the evidence

It is important to realise that ovarian surgery cannot be regarded as a treatment modality that can be used to manage the PCO in general and that it has limited value in the PCO trying to conceive. This is mainly due to the relatively short duration of the effect, of only about 12 months.

In utilising ovarian surgery in the PCO patient wishing to conceive, it is important to remember that the procedure is not without complications or risks. These are mainly a 27% chance of developing dense adhesions, as well as the risk of diminished ovarian reserve volume.

PCOS is a well recognised condition that causes considerable morbidity. However, clinical examination is still hindered by imprecise scoring systems, the laboratory analytical techniques and reference ranges are inadequate.

Finally imaging appears to be irreproducible. Therefore, for now, or until something better comes along, a pragmatic approach may have to be taken in the management of the individual, depending on her particular symptoms and needs.