A STUDY OF DIFFERENT PHENOTYPIC PRESENTATIONS OF POLYCYSTIC OVARIAN SYNDROME: AN INSTITUTIONAL EXPERIENCE

Dr. Malavi ka J.C MS, DNB (OBG). Assistant professor, Department of Obstetrics and Gynecology, S.S.Institute of Medical Sciences and Research Centre, Davangere, Karnataka, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (2), 291-296 292 and post receptor signaling pathways, which accounts to variety of clinical presentations observed in hormonal disorders. This fact becomes further complicated in PCOS wherein more than one hormone is modified. Women with PCOS manifest with hypothalamic-pitutary-ovarian axis abberations, hyperinsulinemia, hyperandrogenism, as well as adipose tissue dysfunctional adipokine secretion, all of which interact in different tissues (muscle, fat,liver and ovaries), thus leading to a variety of phenotypic presentations 1,3 .
The Rotterdham criteria used to diagnose PCOS requires the presence of atleast 2 of the features: oligo/anovulation, clinical / biochemical hyperandrogenism and ultrasound appearance of polycystic ovarian morphology. In 2006, the Androgen Excess Society (AES) pointed out that PCOS is basically anhyperandrogenic disorder and hence demonstration of acne, hirsuitism and /or biochemical hyper-androgenism becomes a sine qua non of PCOS diagnosis. The second criteria required for the diagnosis of PCOS according to AES is either oligo/anovulation or polycystic ovarian morphology 2,5 .
The introduction of different phenotypes based on Rotterdham criteria makes PCOS represent a continuum of symptoms. PCOS may start gradually as a hyperandrogenic disorder and then lead on to anovulation or vice versa.

Aim of the study:-
To study the different clinical presentations among women with PCOS and to categorise them into different phenotypes. Methods:-Type of study: A hospital based explorative study.

Place of study:
All women attending gynecology out-patient department at SS Institute of Medical Sciences and Research Centre with the complaints of menstrual irregularities, infertility and features of hyperandrogenism.

Duration of study: For 2 years between December 2014 to December 2016
Sample size: A total of 120 patients were recruited during the study period after taking informed consent.
Inclusion criteria: Those women who were diagnosed with PCOS according to the Rotterdham criteria were recruited irrespective of the age.
Exclusion criteria: Those women with non-ovarian causes of hyperandrogenism and infertility were excluded.
Study procedure: In OPD, a detailed history was taken. History was noted with respect cyclicityof menses, duration of menses and history of amenorrhea was noted. History suggestive of hypothyroidism (excessive weight gain, menstrual irregularities,menorrhagia) hyperprolactinemia (scanty menses, amenorrhea, premenstrual spotting, secretions from breast) were elicited.
General physical examination was done to note the height, weight and BMI. Clinical signs of hyperandrogenism like acne, hirsuitism were noted. Signs of hyperinsulinemiasuch as acanthosisnigricanswas looked for.
Ultrasound evaluation was done in relevant patients and polycystic ovarian morphology was diagnosed when 12 or more follicles were visualized measuring 2 to 9 mm or when the ovarian volume bigger than 10 ccm 4 .
Routine blood investigations such as complete hemogram, random blood sugar and urine routine examination were done. Hormonal evaluation comprising of serum thyroid stimulating hormone, s.prolactin, serum FSH, serum LH, serum Testosterone was done.

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For women who wished to conceive, serial follicular monitoring was done to document the presence of absence of ovulation. Those women with anovulation were subjected for ovulation induction according to the institution protocols.

Results:-
Out of 120 women who were recruited for the study, 18 were adolescents and 102 women were more than 20 years of age .Adolescents were studied separately owing to diagnostic difficulties.
Serial follicular monitoring was done in all women with PCOS to document the presence or absence of ovulation. Out of 120, ovulation was documented in 22 (21.56%) of them.
After collecting and analyzing the data, all adolescents and women were assessed for 3 features of PCOS namely, presence of oligo/anovulation, clinical /biochemical evidence of hyperandrogenism and ultrasound appearance of PCOM. The classification of phenotypes was done accordingly, as demonstrated in Table 1: The ultrasound definition of polycystic ovarian morphology is the presence of >/= 12 follicles with a 2-to 9-mm diameter on the ovary. Ovarian volume of >10 ml is also suggestive. One ovary consistent with polycystic ovarian morphology is sufficient for the diagnosis 4 . Although various studies have shown that polycystic ovarian morphology may also be found in 20-30% of normally ovulating women.
Four different phenotypes of PCOS have now been identified using the possible combinations of these criteria 9,10 :  Type A: hyperandrogenism, chronic anovulation and polycystic ovaries.  Type B: hyperandrogenism and chronic anovulation.  Type C: hyperandrogenism and polycystic ovaries.  Type D: chronic anovulation and polycystic ovaries No single test is considered gold standard for the diagnosis of polycystic ovarian syndrome. A multimodality approach is required to diagnose the syndrome of polycystic ovaries.
The diagnosis of PCOS is all the more challenging in adolescent girls owing to menstrual irregularity due to anovulation which is commonly observed for few years after the onset of menarche.A high index of suspicion needs to maintained when an adolescent persists to have menstrual irregularity for more than two years after menarche. With respect to features of hyperandrogenism in adolescents, slight acne and hirsuitism is an anticipated problem because of transient functional hyperandrogenism and hence it is not of clinical significance. Hence, the combination of ultrasound and androgen evaluation will help to arrive at the diagnosis in an adolescent 6 .
Analysis of the study done reveals that PCOS can manifest with spectrum of symptoms, with the commonest among all age group being menstrual irregularity presenting as oligomenorrhea. Further, infertility is commonly seen among the reproductive age group women owing to anovulation. Hyperandrogenismis considered as the cardinal feature by AES criteria and it was demonstrated in women in our study. An ultrasound demonstration of polycystic ovarian morphology was seen in 99 (82.5%) women. An ultrasound appearance of PCOM is the result of chronic anovulation, one of the chief causes being PCOS. Other causes of chronic anovulation also needs to be excluded at this point.
The variability of presentation of women with PCOS,with some of them having full blown syndrome(severe PCOS) to others having only 2 of the 3 features point towards the fact that PCOS is continuum of symptoms. Women with mild or ovulatory PCOS can later on in life progress to develop severe PCOS 11 . A tailor made approach is required towards the diagnosis and management of different phenotypes. Adolescents who present with menstrual irregularity can be managed with oral contraceptives and those who come with acne can be managed with oral contraceptives with or without antiandrogens 12 . Women presenting with infertility as chief complaint benefit from weight reduction and metformin which are known to improve the insulin sensitivity and ovulation induction can be done with 295 clomiphene citrate or recombinant FSH. Laparoscopic ovarian drilling may be resorted to in women not responding to ovulation induction drugs.
PCOS is known to be associated with significant cardiometabolic risk like dyslipidemia,hyperglycemia, later on in life. Hence, a clinician should not only address the problem the woman seeks but also advise a woman with PCOS to embrace a healthy lifestyle, healthy eating habits and regular exercise to counter the long term effects of this metabolic syndrome 13,14 .

Conclusion:-
PCOS is a heterogenouscollection of signs and symptoms, which form a spectrum of disorder, with mild variety seen in some women and full blown disorder seen in others. PCOS is viewed as a lifelong disorder with the syndrome progressing from mild to severe variety later on in life.
No single test forms the gold standard diagnostic test in the diagnosis of PCOS. PCOS is a syndrome and it is a diagnosis of exclusion. Hence, other endocrinopathies such as Non Classical Congenital Adrenal Hyperplasia, Cushing's syndrome, acromegaly, hyperprolactinemia,hypothyroidism,premature ovarian failure, virilizing adrenal or ovarian tumor needs to be excluded.
A tailor made approach needs to under-taken in the management of women presenting with PCOS. Since PCOS is associated with significant cardiometabolic risk in later life, all these women need to be advised to embrace healthy lifestyle, healthy nutritional habits and regular exercise.