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Article by: Morshed
What is PCOS?
Polycystic ovary syndrome (PCOS) is a complex endocrine disorder affecting many women worldwide. It is characterized by enlarged and dysfunctional ovaries, excess androgen levels, and insulin resistance. The exact cause of PCOS remains unclear, but factors like insulin resistance, hyperandrogenism, genetics, and environmental influences are thought to play a role. PCOS is associated with various complications, including cardiovascular diseases, type 2 diabetes, metabolic syndrome, depression, and anxiety.
Managing PCOS involves weight loss through exercise and diet, along with various medications like oral contraceptives, antiandrogens, insulin sensitizers, and ovulation inducers. Currently, no medication is specifically approved by the FDA for PCOS, and many treatments are used off-label. Drug repurposing is being explored as a potential avenue for finding new therapeutic options.
This review provides a comprehensive overview of PCOS, its diagnosis, etiology, and management. It discusses both internal and external factors contributing to the syndrome and highlights various medications used in its treatment, including some that have been repurposed from other indications. The review emphasizes the need for further research to better understand PCOS and develop more effective treatments.
Epidemiology
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged females worldwide, affecting 5% to 15% of females depending on diagnostic criteria. The Rotterdam criteria have a broader prevalence compared to the National Institute of Health 1990 Criteria. In the United States, PCOS is estimated to affect about 5 million reproductive-aged females, resulting in approximately $4 billion in annual healthcare costs for diagnosis and treatment, excluding costs associated with related conditions.
PCOS is linked to various conditions, including infertility, metabolic syndrome, obesity, impaired glucose tolerance, type 2 diabetes, cardiovascular risk, depression, obstructive sleep apnea (OSA), endometrial cancer, and non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH). It has also been found to have a higher prevalence in first-degree relatives of affected individuals, along with associations with prepubertal obesity, congenital virilizing disorders, above-average or low birth weight, premature adrenarche, and the use of valproic acid as an antiepileptic drug. Additionally, studies suggest a higher prevalence of PCOS in Mexican-Americans compared to non-Hispanic whites and African Americans.
Etiology and Risk Factors:
PCOS has 2 types of causes: External and internal.
External consists of epigenetic mechanism, environmental toxicants, being physically and mentally stressed, poor diet etc.
Internal factors consist of insulin resistance, hyperandrogenism, inflammation, oxidative stress, obesity.
What is the diagnosis for this?
PCOS is a challenging condition to diagnose, as there is no specific test for it. Instead, a process of differential diagnosis is used to exclude other relevant disorders based on symptoms and investigations. Hyperprolactinemia, thyroid disease, Cushing's syndrome, and adrenal hyperplasia are among the conditions that need to be ruled out.
To establish a differential diagnosis for PCOS, healthcare providers may consider past medical history, weight changes, and symptoms of insulin resistance. Recommended investigations include pelvic examination, transvaginal ultrasound, and hormone level measurements. The National Health Service (NHS) criteria for PCOS include irregular or infrequent periods, elevated androgenic hormones, and polycystic ovaries observed through scans.
The Rotterdam PCOS diagnostic criteria are commonly used in adults, where the presence of two out of three criteria, which are clinical or biochemical hyperandrogenism, ovulatory dysfunction, or polycystic ovaries on ultrasound, confirms a PCOS diagnosis.
How to manage and keep it under control?
The management of PCOS and the choice of therapy depend on the individual patient and her specific priorities. Complications can range from fertility issues and menstrual regulation to weight reduction and relief from hyperandrogenic symptoms like acne, hirsutism, or androgenic alopecia. Since there is no single ideal treatment for all women with PCOS, physicians often resort to symptomatic therapy to address specific symptoms and concerns on a case-by-case basis. Individualized approaches are necessary to achieve the best possible results.
To keep this under control one can follow some natural methods like doing exercise, keeping correct body weight, having good diet.
But doctors can suggest medication too if the situation is out of control as current management and available medications for PCOS are only moderately effective, leaving some cases untreated despite various treatments. Pharmacological therapies are reported to be effective in about 60% of patients. Recent studies suggest that using complementary and alternative medicine (CAM) as an adjunctive therapy may benefit PCOS management. CAM is a well-known approach, with more than 70% of PCOS patients trying it at some point during their disease. CAM can be classified into three classes based on its primary therapeutic input: nutritional, psychological, physical, or a combination of these approaches.
One significant advantage of CAM is that patients often accept these methods due to their beliefs and cultural background, leading to improved adherence and tolerance to the therapy. Previous studies have shown that various CAM methods, such as traditional Chinese medicine (TCM), immunotherapy, diet therapy, psychotherapy, spa treatments, yoga, Tai Chi, and oxygen therapy, can effectively reduce the severity of PCOS and its complications. The review focuses on two critical subgroups of CAM that have shown efficacy in PCOS management.
The pathogenesis of PCOS is not fully understood, but it is believed to involve various factors such as epigenetic changes, obesity, inflammation, and physical inactivity, which can worsen the syndrome. As there is no specific medication or cure for PCOS, symptomatic therapy using different agents like contraceptives, oral antidiabetics, and antiandrogens is commonly employed after lifestyle modifications and supplementary advice.
In terms of repurposing, there is potential for other approved drugs to have beneficial effects on PCOS. Since these drugs have already undergone comprehensive studies regarding their efficacy and safety, they offer a more straightforward pathway for finding novel treatments. However, there is still much to discover and investigate to gain a better understanding of PCOS's pathogenesis and to target the mechanisms with appropriate medications.
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