PCOS (Polycystic Ovary Syndrome)

PCOS (Polycystic Ovary Syndrome) is a common hormonal disorder in our country. It is a condition about which many physicians comment without having full command of the subject and sometimes treat incorrectly due to misdirection. From time to time, patients may panic, think they are entering early menopause, and may be unnecessarily started on IVF (In Vitro Fertilization) treatment. In PCOS, follow-up and treatment must be carried out by physicians who are experts in the field, with detailed information provided to the patient. For example, using intensive hormone therapy or long-term birth control pills solely for cycle regulation is not correct.

PCOS (Polycystic Ovary Syndrome) is a common hormonal disorder in women of reproductive age. It is seen with a frequency of approximately 6–8%. Today, there are still debates about the causes and diagnostic criteria of the syndrome. For a diagnosis of PCOS, it is necessary to have clinical

and/or biochemical evidence of elevated androgen hormones together with ovulation problems, as well as the detection on ultrasound of the typical appearance in the ovaries that we call polycystic ovary.

PCOS, the most common cause of chronic anovulatory infertility, is a multisystem reproductive–

metabolic syndrome and is emerging as a public health problem today because it carries long-term health risks such as type 2 diabetes, elevated lipids, cardiovascular

disease, and endometrial hyperplasia and, in the long term, an increased risk of uterine cancer.

PCOS usually presents from adolescence onward with menstrual irregularities (absence of menstruation, frequent or very infrequent periods, intermenstrual bleeding, irregular bleeding), signs of elevated androgen, that is, male hormone levels (hirsutism, acne, oily skin, male-pattern hair loss), and infertility due to ovulation problems.

Due to a disruption in the coordination between the LH and FSH hormones secreted from the pituitary gland in the brain and the ovaries, regular monthly ovulation does not occur in the ovaries. 
To diagnose PCOS, it must be proven that there are no other diseases that could cause a similar clinical picture. Although the exact causes are not known, PCOS can be considered a common and complex disease that arises from the interaction of genetic and environmental factors.

In polycystic ovary syndrome, the aims of treatment are:

·       Treatment aimed at achieving pregnancy

·       Regulation of menstrual cycles

·       Reducing circulating androgens (male hormones)

·       Protection of the endometrium (inner lining of the uterus)

·       Maintaining a normal body weight

·       Preventing diseases that may develop as a result of insulin resistance

The symptoms and their severity differ in every woman, and treatment methods are determined accordingly.

TREATMENTS FOR WEIGHT CONTROL

A reduction of 5–7% in body weight leads to improvement in signs of hyperandrogenism (elevated male hormones) in approximately 75% of women. In women with PCOS, there is no evidence that any particular diet regimen is more effective than another. The most effective treatment for weight loss is diet and regular exercise.

The best way to get rid of obesity is balanced nutrition. We should avoid fatty foods. We should consume white meat and vegetables as much as possible. We should prefer foods with low calories. We should exercise whenever we find time and drink plenty of water during the day. Remember that exercising and drinking plenty of water not only prevent us from becoming overweight, but also help us maintain a healthy life. Diets prepared under the supervision of specialist dietitians should be followed. We often say it is good to lose weight, but wish we would not gain it back; however, what we fear often happens.

Exercising is very important.

Losing weight is not possible with diet alone. The sedentary lifestyle we reinforce by sitting at a desk, using elevators, and parking our car as close as possible, and the weight this habit brings us, can be countered by the energy we expend by walking, playing tennis, swimming, or at least doing our own housework, combined with proper nutrition. This will bring us to an excellent level in terms of both health and appearance.

TREATMENT OF ACNE AND EXCESS HAIR

In PCOS, the aim of acne and hirsutism treatment is to reduce androgen production or to increase the binding of androgens in the blood to binding proteins. In this way, the effect of androgens on tissues will decrease.

In treatment, the combination of estrogen and progesterone is the first-line therapy for women who are not considering pregnancy. Estrogen suppresses the secretion of luteinizing hormone in the pituitary, which reduces androgen production in the ovaries. Estrogen also increases the production of sex hormone–binding globulin in the liver, thereby lowering testosterone levels in the blood.

Oral contraceptives improve acne and hirsutism but do not have a positive effect on insulin resistance. Treatment is directed at the underlying cause. Cosmetic procedures and medication may be needed simultaneously or at different times. Generally, benefit should be sought from both approaches. Despite effective hair-removal methods, there is still no ideal treatment method. Shaving is not recommended. Waxing can be done. The best option is laser epilation. Using these methods together with medical treatment is a more beneficial approach.

Treatment of hirsutism requires patience because the life cycle of hair follicles is 6 months. Therefore, it takes at least 3–6 months of medication use to see an effect. Hirsutism usually decreases with drug treatment over 6–18 months and then enters a new plateau phase. The most important factor showing the effectiveness of treatment is the shortening of the time the patient needs for hair removal.

POLYCYSTIC OVARY SYNDROME AND USE OF DIABETES TABLETS

Insulin resistance plays a key role in the development of PCOS, and the treatment approach involves insulin-lowering drugs known as diabetes medications. Studies have shown that the most effective agent is metformin. Metformin was first used in the treatment of type 2 diabetes. Its positive effect on glycemic control in diabetes and its effect on insulin resistance in PCOS have been demonstrated.

Metformin increases glucose transport and reduces blood insulin and androgen levels in cases of high insulin and high androgen. While lowering insulin levels in diabetic patients, it does not cause hypoglycemia. By inhibiting glycogenolysis and reducing excessive hepatic glucose production, it does not increase insulin levels. Metformin increases insulin sensitivity in tissues.

Studies have reported that metformin treatment reduces high blood sugar and elevated male hormones independently of changes in body weight. In the vast majority of women with PCOS, improvement in menstrual irregularities and ovulation function has been observed.

There are studies suggesting that after metformin use, spontaneous pregnancy losses decrease in women with PCOS. Scientific studies have also shown that metformin reduces the risk of developing gestational diabetes, which is more common in pregnancy.

The main guiding factor in treatment is whether the patient desires pregnancy.

• Lifestyle modification

First, change your sedentary lifestyle. In polycystic ovary syndrome, weight loss alone leads to regression of most existing complaints. If you lose 10% of your body weight, you will see a marked improvement in your menstrual pattern. The target in weight is to reduce your body mass index below 27. To achieve this, stay away from stress, exercise regularly, and follow a low-fat diet with high fiber content.

• Birth control pills

If there is no desire for pregnancy, birth control pills can be used to regulate menstruation. Birth control pills improve hormone balance, and accordingly complaints such as excess hair, weight gain, and oily skin regress. In the long term, this treatment reduces the increased risk of endometrial (uterine lining) cancer. These effects are particularly evident with 12–36 months of use.

• Insulin-sensitizing agents

Some drugs used in diabetes are also used in PCOS. These drugs act by increasing insulin sensitivity. Their effectiveness shows individual variation. With 3–6 months of metformin use, menstrual regularity is achieved in about half of patients. In addition, they have positive effects on excess hair with long-term use. They also reduce the increased miscarriage rates and gestational diabetes rates seen in polycystic ovary syndrome. In women undergoing infertility treatment, beneficial effects on pregnancy rates and pregnancy course have been demonstrated.

• Infertility treatment

In patients who cannot achieve pregnancy due to ovulation disorders, clomiphene citrate, metformin, gonadotropins, GnRH agonists or antagonists can be used to stimulate egg development. The procedure called ovarian drilling, in which the outer shell of the ovaries is destroyed using laser or electrical energy, can be used in a very limited number of selected cases.

• Treatment of excess hair

There are many methods for treating excess hair. The best response is usually obtained by using these methods together. For this purpose, birth control pills and some adjunctive medications are used. Once suppression is achieved with these methods, adding epilation techniques yields very good results. In PCOS patients, if epilation methods are used without first achieving hormonal balance, the effects are temporary because new hair follicles develop after a while.