Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorder affecting 2.2 to 22.5% women in the reproductive age. The prevalence of PCOS is increasing world over and is showing a galloping increase in India. Our recent study reported higher prevalence (28-35%) of PCOS among Kashmiri women in reproductive age group suggesting that Kashmir valley is also observing the epidemic said the noted Endocrinologist Prof Mohd Ashraf Ganai. This could have devastating consequences on health structure and economy in future, since it is associated with multiple and detrimental co morbidities. Besides the worrying factor is that the majority of women are unaware of the condition and even the care givers and clinicians are not sensitized to the co morbidities associated with the condition.
However, majority of patients and clinicians are bothered over cosmetic issues and infertility. It is worth mentioning that the disorder is associated with a group of metabolic aberrations including obesity, abnormal glucose tolerance (AGT), insulin resistance (IR), non-alcoholic fatty liver disease (NAFLD), sleep apnoea, neuropsychiatric problems besides having high risk for strokes, cardiovascular diseases (CVD), and malignancies etc.
The disorder is characterized by hypeandrogenism (excessive levels of male sex hormones such as testosterone), anovulation (ovulatory dysfunction i.e. when the ovaries do not release an oocyte), insulin resistance (hyperinsulinemia-high levels of insulin in blood) and polycystic ovarian morphologic features in adolescent and adult females of reproductive age. In our experience all women with PCOS are not overweight, and all overweight women have not PCOS. As the condition can be grouped as one of the lifestyle disorders with close link to conditions like diabetes mellitus, metabolic syndrome, CVD etc. Accordingly it is common in the family members with these diseases.
PCOS is a set of symptoms with hyperandrogenism as one of the primary symptoms. In such cases, it presents with symptoms such as acne vulgaris (pimples), alopecia (hair fall), menstrual cycle disturbances (irregular or absent periods), polycystic ovaries (small necklace pattern cysts that contain small collections of fluid in ovaries, actually representing eggs arrested during their growth), infertility (failure to conceive), hirsutism (unwanted hair growth on the face or body) etc.
It is pertinent to mention that all women with PCOS do not experience all of the symptoms and in fact the presentation may change with time and get worse, if the woman becomes obese. PCOS is believed to be a hereditary disorder, the result of genetic variations resulting in a complex genetic attribute. It may run in families, thus may have polycystic ovary with no visible symptoms. Plasma levels of insulin, a hormone produced in the pancreas that allows cells to use glucose (sugar), rise due to its in effectives in the target tissues (insulin resistance).
This superfluous insulin may affect the ovaries by increasing androgen (male hormone) production, which may lead to features of masculination such male pattern hair growth or loss with acne vulgaris in women in addition to interference with the sheeding on eggs from ovaries (ovulation).Insulin resistance as the underlying cause of PCOS has unlocked a new debate among clinicians and scientific community across the globe and has paved way for use of insulin sensitizers such as metformin or glitazones in its treatment. Research has also shown that women with PCOS have low-grade inflammation and insulin resistance along with low-grade inflammation seems to link it with others lifestyle disorders such as diabetes mellitus, coronary heart disease, metabolic syndrome etc. Infertility, one of the manifestations of PCOS being greatly ostracized, is very common and needs particular attention. This has far reaching social consequences especially in society like ours often setting grounds for divorce.
Women with PCOS including adolescent girls assume that they are no longer marriageable, present with low self-confidence due to facial hair (hirsutism) and fear that they might be viewed as a burden on families, communities or societies. There is no solitary criterion for the diagnosis of this syndrome. Rather, it is diagnosed based on a combination of the results of clinical and ovarian morphology in ultrasound. The scarcity of distinct diagnostic criteria makes PCOS diagnosis perplexing to majority of the clinicians.
Since the etiology (causation) of PCOS is not clear, the treatment by and large remains to be empirical. Currently lifestyle management is the most important strategy in addition to some limited medications (insulin sensitizers and anti-androgens). The increase in reproductive disorders like PCOS and infertility has been linked to sedentary lifestyle and environmental exposure to harmful agents like endocrine disruptor chemicals (EDC’s) including pesticides, plasticizers etc. Hence, we need to be aware and understand the risk factors resulting in adverse health effects.
There is sketchy data about the prevalence of PCOS and the associated co morbidities among Indian women. Accordingly amulticentric National Task Force study (10 centres) with funding of approximately RS 9 Crore, destined to landscape the prevalence of PCOS along with its co morbidities. It is matter of pride that the study is coordinated by SKIMS Srinagar in the department of Endocrinology. This study likely to be completed by 2020 will generate the actual prevalence and co morbidity burden of the disease in the community.
This study will pave way for hard core research in unravelling the cause of the condition in addition to formulation preventive and novel treatment strategies. A team of 102 researchers, clinicians cum experts (PCOS group) across the country are involved in the study. The flagship project of ICMR, New Delhi will provide a new way of thinking about PCOS and opens up a wide range of opportunities for further in-depth research says Prof. Ashraf Ganie Chief Coordinator.
Sher-i-Kashmir Institute of Medical Sciences, Srinagar has set up “PCOS Station’’ inaugurated by Prof. Omar Javed Shah, Director SKIMS & Ex-Officio to Government, a one-stop facility for PCOS comprehensive care and for capturing clinical data that remains functional on every Thursday. Commenting on setting up a PCOS station at SKIMS, the first of its kind in the country Dr. Ganie said that average woman sees at least 2-3 dissimilar physicians/clinicians of diverse expertise before they catch relevant clinician for proper diagnosis.
Unfortunately the women with PCOS are being treated with cosmetic measures (laser hair removal, plucking, trimming, waxing, or bleaching, skin creams etc.) for dermatological symptoms or by oral contraceptive pills for the reasons of menstrual irregularity. Therefore, for most women it works for their issues with skin or making their periods regular without fixing the underlying problem. Countless women labelled as PCOS go for many rounds of IVF and undergo devastating journey.
The rise of PCOS among young girls is alarmingly high. During their visit to various educational institutions in Kashmir, they came across an alarming number of young girls with PCOS. “Every other girl complained about irregular periods, acne or excessive hair growth. Diet and lifestyle changes involving regular exercise are recommended as the first-line approach in treating PCOS said Dr. Aafia Rashid, researcher, Advance Centre for Human Genetics, SKIMS.
With a fear of the rise in cases of women with PCOS, addressing it within the public sphere is imperative, in order to fully understand and adequately address the issue of PCOS and associated outcomes. The undesirable reproductive and metabolic offshoot advocates early screening and diagnosis of PCOS. It is one of the most critical, under-diagnosed, underfunded and neglected areas of health which can lead to life-long complications.
PCOS leads to extreme stress levels among college going girls and even after marriage. Hence it contributes as one possible cause for late marriages in this part of the world. PCOS is relatively misunderstood globally and particularly in Asia, thus spreading awareness seems to be imperative. There is a need for increased awareness, early recognition of symptoms and a multidisciplinary approach for diagnosis of PCOS. Awareness of PCOS symptoms and complications is essential for early treatment and to prevent further serious complications of it. The public is largely unaware of the condition and health care providers need to fully understand it. In this regard we are going to organise a periodic training programmes, workshops to sensitize clinicians and public about the presentation and consequences of the disorder.
(Author is a Research Scientist)