POLYCYSTIC OVARIAN SYNDROME IN ADOLESCENT AGE GROUP AT TERTIARY CARE CENTRE.

Manra singh 1 And Usha rawat 2 . 1. PG resident third year, Obs and Gynae Department, Susheela Tiwari Govt. Hospital, Haldwani, Uttarakhand. 2. Professor, Obs and Gynae Department, Susheela Tiwari Govt. Hospital, Haldwani, Uttarakhand. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 22 February 2019 Final Accepted: 24 March 2019 Published: April 2019 Polycystic ovarian syndrome is one of the gynaecological problems during adolescence. It is one of the most common endocrine disorder affecting 5-10% women worldwide (4) . This study was conducted to study the clinical and biochemical features of PCOS because it is important to screen and diagnose adolescent PCOS in order to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, metabolic syndrome and endometrial cancer in PCOS patients. Material and methods: Cross sectional study conducted on 50 patients attending the OPD and IPD at Dr. Susheela Tiwari Govt. Hospital for menstrual irregularities and other gynaecological problems. Conclusion: Out of the PCOS patients studied at Susheela Tiwari Hospital , Haldwani,25% were overweight and 8% were obese, residing in urban areas, Waist hip ratios of 62% patients in the study group were >0.80. 62% patients had menstrual irregularities and 44% patients had clinical features of Hyperandrogenism. However, biochemical Hyperandrogenism was seen only in 10% of patients. 20% and 12% patients had a family history of Diabetes Mellitus and Hypertension respectively. Hypothyroidism also accompanied a small percentage of patients with PCOS, the percentage being 20%. LH/FSH ratio was raised in 14% patients and ultrasound features of PCOS were found in a large group of patients, the percentage being 60%.

It is a challenging public health problem affecting 1 in 5 women of reproductive age group (5) and is a frustrating experience for women.
Polycystic Ovarian Syndrome was originally described in 1935 by Stein and Leventhal as a syndrome manifested by Amenorrhea, Hirsutism and Obesity associated with enlarged polycystic ovaries (4) .
It affects 20-30% of reproductive age group women and 30% of regularly menstruating girls. The common symptoms include irregular menses, cutaneous disorders (acne, hirsutism) and obesity (6)(7) . Adolescent girls require long term committed treatment so that they don't land up in infertility in future This heterogeneous disorder is characterized by excessive androgen production by ovaries and is a multifactorial and polygenic condition.  In this Syndrome, due to insulin resistance, there is Hyperinsulinemia which participates in the ovarian hormone dysfunction. Insulin alters the ovarian steroidogenesis independent of gonadotropin secretion (8) .
Insulin increases the ovarian androgen synthesis by increasing LH pulse frequency at Pituitary gland and due to insulin resistance there is risk of gestational diabetes, Type 2 Diabetes Mellitus, obstructive sleep apnea, cardiovascular disease, endometrial cancer and poor quality of life. Insulin inhibits the hepatic synthesis of sex hormone binding globulin the main circulating protein that binds to testosterone, thus increasing the production of unbound or bioavailable testosterone (8) .
Acanthosis nigricans is a reliable marker of insulin resistance in hirsute women. This thickened, velvety, pigmented lesion is most often found in the vulva, may be present in the axilla, over the nape of neck, below the breast and on the inner thigh. 1. HAIR-AN syndrome consists of 2. Hyperandrogenism (HA) 3. Insulin resistance (IR) and 4. Acanthosis nigricans (AN).

Figure 4:-acanthosis nigricans
Being a tertiary care centre a lot of adolescent girls attend the OPD with menstrual irregularities and other features associated with PCOS. This study was conducted to study the clinical and biochemical features of PCOS because it is important to screen and diagnose adolescent PCOS in order to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, metabolic syndrome and endometrial cancer in PCOS patients.
Although adolescent's concerns are often cosmetic, if left untreated these girls are at risk for diabetes, metabolic syndrome, and infertility as they mature. Efforts have been made to diagnose and treat PCOS to minimize the development of symptoms and prevent the onset of cardiovascular and metabolic disturbances.

Sample Size
Study was conducted on 50 adolescent girls attending Obstetrics and Gynaecology OPD and IPD at Dr. Susheela Tiwari Government Hospital for menstrual irregularities and other gynaecological problems .

Methodology:-
Written and informed consent was obtained from the all the adolescent patients and their parents/guardians agreeing to participate in the study and confidentiality was maintained. All patients were subjected to detailed clinical history, menstrual and family history. Height and Weight were measured and BMI was calculated. Detailed history was 1173 followed by Ultrasonography for uterus and adnexa. Hormone profile was done on all adolescent girls (preferably on day 2 or day 3 of menstrual cycle) which included: If none of the criteria for PCOS were fulfilled, patient was investigated to rule out other causes of menstrual irregularities.All patients were subjected to routine blood investigations.
Result:-Chart 1:-Relation Between Age And Pcos 50% patients lie between the age group of 10-14 years,14% lie between the age group of 15-16 years and 36% lie between the age group of 17-19 years.
Chart 10:-Relation Between Hip Circumference And Pcos 6% patients had hip circumference less than 75cm, 58% patients had hip circumference between 76-100 cm. and 36% patients ha hip circumference between 100-125cm   In this study 14% patients had raised LH/FSH ratio whereas the other 86% had normal LH/FSH ratio

Chart 16:-Relation Between Serum Testosterone And Pcos
In this study 10% of PCOS patients had raised Serum Testosterone levels whereas the other 90% patients had normal serum testosterone levels. In this study 10% of PCOS patients had raised Serum Dihydrotestosterone levels and the other 90% had normal Serum Dihydrotestosterone levels.

Chart 18:-Relation Between Serum Dheas And Pcos
In this study 8% patients had raised Serum DHEAS levels and 92% had Serum DHEAS values normal.

Chart 19:-Relation Between Serum Prolactin Levels And Pcos
In this study all the patients had normal serum prolactin levels In this study 4% patients had raised Serum Prolactin levels whereas 96% had normal serum prolactin levels.

Chart 21:-Ultrasound Suggestive Of Pcos
In this study 60% patients had ultrasound features suggestive of PCOS. In 40% patients there were no ultrasound features suggestive of PCOS.

Summary And Conclusion:-
1. Out of the PCOS patients studied at Susheela Tiwari Hospital , Haldwani,25% were overweight and 8% were obese. 2. Most of the patients who had PCOS were residing in urban areas. This is also supported by other studies which explain higher incidence of PCOS in urban population as a result of lifestyle changes. 3. 90% of the PCOS patients in the study were non vegetarian. 4. In this study 20% and 12% patients had a family history of Diabetes Mellitus and Hypertension respectively. 5. Waist hip ratios of 62% patients in the study group were >0.80 which explains the correlation between central obesity and PCOS. Some studies have also shown that presence of central obesity worsens the clinical and biochemical profile of PCOS patients. 6. In this study 62% patients had menstrual irregularities and 44% patients had clinical features of Hyperandrogenism. However, biochemical Hyperandrogenism was seen only in 10% of patient explaining that biochemical and clinical hyperandrogenism in PCOS are distinct entities and no androgen correlates well with clinical hyperandrogenism, acne, or hirsutism. 7. OGTT being a screening tool for future predisposition for Diabetes Mellitus was deranged in 10% patients only. 8. Hypothyroidism also accompanied a small percentage of patients with PCOS, the percentage being 20%. 9. In this study, LH/FSH ratio was raised in 14% patients. The results show that LH/FSH ratio is not a characteristic attribute of all PCOS women which is also proved by some other studies. 10. Serum prolactin levels were within normal limits for all the patients included in this study. 11. In this study, ultrasound features of PCOS were found in a large group of patients, the percentage being 60%.
Ultrasound is an easy and cost effective tool for diagnosis of PCOS. Ultrasound finding of PCOS thus can be followed up with hormonal profiles and both can be correlated clinically. 12. Thus, we conclude that best efforts have been made in this study to identify the clinical and biochemical features of PCOS in order to screen and diagnose adolescent PCOS to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, and even endometrial cancer. 13. Efforts have been made to diagnose and treat PCOS to minimize the development of symptoms and prevent the onset of cardiovascular and metabolic disturbances.