INTRODUCTION

The polycystic ovary syndrome (PCOS) is a hyperandrogenic

disorder associated with chronic oligo-anovulation and
polycystic ovarian morphology. It is often associated with
psychological impairments, including depression and other
mood disorders and metabolic derangements, chiefly insulin
resistance and compensatory hyperinsulinemia, which is
recognized as a major factor responsible for altered
androgen production and metabolism. Most women with
PCOS are also overweight or obese, further enhancing
androgen secretion while impairing metabolism and
reproductive functions and possibly favoring the
development of the PCOS phenotype. The definition of PCOS
has led to an impressive increase of scientific interest in this
disorder, which should be further directed to improve
individualized clinical approaches and, consequently
therapeutic strategies. It 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
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
 BODY
Historical Aspects of PCOS
• Vallisneri gave the first histological description of the
polycystic ovary, 1721
• Sclerocystic changes in the ovary described by Chereau, 1844
• Class description of a bearded women with DM, Achard/Thiers
1921
• In 1935, Stein and Leventhal described 7 women with bilateral
enlarged PCO, amenorrhea or irregular menses, infertility and
masculinizing features.
• This seminal paper introduced clinicians to the concept of
reproductive endocrinopathies.

PCOS-Epidemiology
• PCOS affects 6.5 to 8% (NIH 1990) of the female population of
reproductive age.
• It’s prevalence among infertile women is 15% to 20%.
• PCOS accounts for 95% of cases of hyperandrogenism
• PCOS is responsible for over 20% of all cases of amenorrhea
• PCOS is responsible for up to 75% of all cases of anovulatory
infertility.
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 released from the ovaries as well as the adrenal
cortex. The excess androgen hormones in the system 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.

Principal genetic targets

• Gonadotropin secretion

• Insulin secretion

• Androgen biosynthesis

• Weight and energy regulation

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 clitoromegal.
 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 miscarriages PCOS
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.
 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:

a. 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.
b. 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 been trialed 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.

Lifestyle and home remedies

To help ease the effects of PCOS, try to:

 Stay at a healthy weight. Weight loss can lower insulin

and androgen levels. It also may restore ovulation. Ask
your health care provider about a weight-control program,
if you need one. Meet with a registered dietitian for help in
reaching weight-loss goals.
 Limit carbohydrates. High-carbohydrate diets might
make insulin levels go higher. Ask your provider if a low-
carbohydrate diet could help if you have PCOS. Choose
complex carbohydrates, which raise your blood sugar
levels more slowly. Complex carbohydrates are found in
fruits, vegetables, whole grains and cooked dry beans and
peas.
 Be active. Exercise helps lower blood sugar levels. If you
have PCOS, increasing your daily activity and getting
regular exercise may treat or even prevent insulin
resistance. Being active may also help you keep your
weight under control and avoid developing diabetes.

Preparing for the appointment

For PCOS, you may see a specialist in female reproductive
medicine (gynecologist), a specialist in hormone disorders
(endocrinologist) or an infertility specialist (reproductive
endocrinologist).

Here's some information to help you get ready for your

appointment.

What ONE can do

Before appointment one must make a list of:

 Symptoms you've been having, and for how long

 Information about your periods, including how often
they occur, how long they last and how heavy they are
 All medications, vitamins, herbs and other supplements
you take, including the dosages
 Key personal and medical information, including other
health conditions, recent life changes and stressors
 Questions to ask your health care provider

Physical Therapy Management

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

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.