Polycystic Ovarian Syndrome

Original Editors - Amanda Tieken from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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INTRODUCTION

L normal ovary, R polycystic ovary

Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder in females of reproductive age. It is characterized by two or more of the following:

1. Irregular menstrual periods
2. Hyperandrogenism
3. Polycystic ovaries.

Unfortunately PCOS is underdiagnosed, frequently taking a long time to be identified, often over a year.

Multiple morbidities are associated with PCOS, including infertility, metabolic syndrome, obesity, insulin resistance, type 2 diabetes mellitus, cardiovascular risk, depression, obstructive sleep apnea, endometrial cancer, and nonalcoholic fatty liver disease . .

Epidemiology

The estimated prevalence of PCOS is 8-13% of women of reproductive age but this varies (up to 20%) depending on the diagnostic criteria used . It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age.

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

Pathophysiology

Polycystic Ovarian Syndrome 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 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.

Characteristics/Clinical Presentation

Signs and symptoms of PCOS include the following: 

• Enlarged polycystic ovaries
• Obesity and central fat distribution
• Hirsutism - male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs
• 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
• Anovulation - failure of the ovaries to release an oocyte
• Amenorrhea - the absence of a menstrual period in women of childbearing age
• Oligomenorrhea - the presence of menstrual cycles greater than 35 days apart
• Dysfunctional uterine bleeding
• Acne related to hyperandrogenism
• Infertility; recurrent first trimester miscarriagesPCOS can make it harder to get pregnant and increase the risk for pregnancy complications and miscarriage. Weight loss and other treatments can improve the chances of having a healthy pregnancy.
• There are pronounced psychological and psychosocial problems that affect health-related quality of life (HRQL).
• Obstructive Sleep Apnea

Diagnosis

There is no single specific test that can be used to accurately diagnose Polycystic Ovarian Syndrome. 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). Investigations that could help arrive at 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.
• Hormonal Blood Tests
  1. Hyperandrogenism - Testing for androgen levels and free androgen index (FAI) is 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 Polycystic Ovarian Syndrome 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:

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.

TREATMENT

Treatment for PCOS usually starts with lifestyle change recommendations; Weight loss - Cornerstone in controlling all derangements seen in PCOS; Regular exercise (30min/day) lowering insulin levels - walking/jogging; Low-carbohydrate diets have trialled but studies have shown no difference in outcomes.

Medical treatments for menstrual abnormalities, hirsutism, and acne are:

• Hormonal contraceptive, either oral contraceptive, patch, or vaginal rings.
• Metformin and anti-androgens may also help.
• The combined treatment with metformin and progesterone-based oral contraceptives could reverse the early stage endometrial cancer into normal endometria along with improvement of insulin resistance in women with PCOS.

Physical Therapy Management

A physiotherapist and dietician are highly recommended as these are considered first-line treatments.

Exercise improves PCOS

Exercise training has shown great improvement in 50% of the women diagnosed with Polycystic Ovarian Syndrome PCOS, by targeting 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.

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

In treating patients with a past medical history of Polycystic Ovarian Syndrome 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.

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

Therapeutic Exercise / Activity / Modalities for PCOS

Physical therapy interventions seek to decrease the main symptoms of polycystic ovarian syndrome (PCOS) by addressing hormonal imbalances, obesity, and seeking to improve the quality of life for these women. High Intensity Interval Training, Cardiovascular training, and Resistance Training help increase heart rate, which have a positive impact on overall physiological effects on cardiovascular health and hormone regulation, including the androgen hormones and insulin sensitivity that lead to symptoms of PCOS. Physical therapy modalities can also aid in the reduction of experienced symptoms in PCOS.

High Intensity Interval Training (HIIT)

High Intensity Interval Training (HIIT) training is a popular style of fitness training that consists of a series of exercises being performed at a fast paced to elicit both an aerobic and anaerobic response.  Anaerobic HIIT is a highly desirable workout because it engages all muscle fibers, the fast twitch as well as the slow twitch. This makes anaerobic HIIT good for a complete training effect. (Anaerobic Exercise - Physiopedia (physio-pedia.com). The benefits of H.I.I.T training for PCOS include improvements of glycemic control, “improvements in aerobic capacity, insulin sensitivity, menstrual regulation and hormonal profiles." HIIT has also been shown to decrease stress, anxiety, and depression level.  

Modalities

Biofeedback:

Transcutaneous electrical nerve stimulation (TENS):

Hot pack/Heat Therapy: