Decoding Polycystic Ovarian Syndrome (PCOS) Kanthi Bansal, Pooja Sharma Dimri, Apoorva Pallam Reddy
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1BASICS
  1. Polycystic Ovarian Syndrome—The Mounting Syndrome
  2. Etiology of Polycystic Ovarian Syndrome2

Polycystic Ovarian Syndrome —The Mounting SyndromeCHAPTER 1

Sonia Malik,
Suyesha Khanijao
 
INTRODUCTION
Polycystic ovarian syndrome (PCOS) is an endocrine disorder without any permanent cure. It is a lifestyle disease affecting a growing number of urban Indian women. Medical practitioners have noted a recent rise in PCOS cases in urban India and attribute it to ‘Westernization,’ modernization, stress, and lifestyle changes. We are in the middle of an alarming trend. More and more women are being diagnosed with polycystic ovarian syndrome (PCOS). The disorder is not new, but it is increasing at a dazzling rate. The prevalence of PCOS is increasing throughout the world in parallel with the rising prevalence of type 2 diabetes mellitus (T2DM). Use of different diagnostic criteria may partly account for it, as has recently been shown in a study from Mumbai.1 PCOS has also been noted to affect 28% of unselected obese and 5% of lean women. In 2006, based on the US data and traditionally lower prevalence estimates, the anticipated economic burden of PCOS in Australia was AU $400 million (menstrual dysfunction 31%, infertility 12% and PCOS-associated diabetes 40% of total costs), representing a major health and economic burden.2 Although there are no such studies from India, but most gynecologists and endocrinologists are perceiving an increase in the number of PCOS adding to the economic health burden of the country.3
 
HISTORY
Hippocrates (460–377 BC) noted, “But those women whose menstruation is less than three days or is meager, are robust, with a healthy complexion and a masculine appearance; yet they are not concerned about bearing children nor do they become pregnant” (Diseases of Women 1.6).4 In Ayurveda, Acharya Sushruta5,6 has mentioned Bandhya a type of, ‘yonivyapada’, whose symptom is amenorrhea or oligomenorrhea. Similarly, Acharya Charaka has described Arajasaka, a yonivyapada indicating amenorrhea.
But it was about 80 years back, a seminal publication in a journal transformed the perception of this disorder. The report by Irving Freiler Stein and Michael Leventhal titled, ‘Amenorrhea Associated with Polycystic Ovaries’, has proven to be a remarkably lasting and influential publication. Popularly known as the 4‘Stein-Leventhal syndrome’, this condition was little understood and females were treated for their immediate gynecologic problems. The long-term sequelae were not well known. The growth in the related literature has been increasing exponentially ever since: the 50 years between 1950 and 2000 saw a little more than 8,000 publications on the topic, whereas the 15-year period between 2001 and 2015 has seen more than 20,000 related publications, a greater than 8-fold increase in the publication rate after 2000,2 thus focusing on not only the growing interest in this disorder but also leading to a better understanding of the disorder.
Polycystic ovarian syndrome is becoming very common affecting women of all ages from adolescence to menopause. The presentation varies across communities and ages, making this a syndromic disorder. Though the most common features usually include excessive weight gain, oligomenorrhea/amenorrhea, increased triglyceride and insulin levels in the blood, acne, hirsutism and hypermenorrhea, it is also associated with menstrual disorders and infertility, usually occurring due to chronic anovulation. PCOS is a heterogeneous disorder of uncertain cause. There is some evidence that it is a genetic disease. This includes the familial clustering of cases, greater concordance in monozygotic compared with dizygotic twins and heritability of endocrine and metabolic features of PCOS. Environment and nutrition, however, seem to be playing a major role in the evolution of this disorder. Ayurveda5 suggests that this is a vata type disorder (Apanvata), though the involvement of other can be there but in some measure. Vata predominance manifests with painful menses, severe menstrual irregularity, low weight, coldness Pitta predominance manifests as hair loss, acne, painful menses, clots and heart problems. Kapha predominance manifests as increased weight, infertility, hirsutism and diabetic tendencies. This varied interpretation of symptoms in the other streams on medicines also suggests that this syndrome is truly heterogeneous in nature. A study by Kar et al.7 from Odisha defines the prevalence of different phenotypes of the disorder and its implications. Various studies from different parts of India suggest that not only is the disorder gaining prominence, but it is also suggesting a relationship with diabetes and metabolic syndrome in the later years. The presence of hypertension in adolescents who are obese, is a risk factor for developing metabolic syndrome in later years in life (Indian good practice guidelines) and studies also indicate that presence of PCOS indicates both diabetes and metabolic syndrome in their families.8
The worldwide prevalence of polycystic ovarian syndrome ranges from 2.2 to 26%. The World Health Organization estimates that it affects 116 million women worldwide as of 2010 (3.4% of women).9 The rates of polycystic ovarian syndrome have been reportedly high among Indian women compared to their Caucasian counterparts, with an estimated prevalence of 9.13% in Indian adolescents.10 Statistics reveal that, in India, 1 out of every 5 women in the reproductive age, and as high as 2 out of every 5 adolescents, are diagnosed with PCOS. PCOS prevalence in India is as high as 22%, which is much higher as compared to that in developed countries.
 
STUDIES ON PCOS PREVALENCE IN INDIA (TABLE 1.1)
The PCOS is believed to be a disease of upper class or rich people.5
Table 1.1   Prevalence of PCOS—various studies
Region
Place
No. of subjects
Study type
Age
Year
Criteria used
Prevalence
Study
North
Lucknow
1520
Community based
18–25
2013
MI or H or both
3.7%
Gill et al.
North
New Delhi
175
Case control
13–18
2010
Rotterdam
46.18%
Ganie et al.
South
Andhra Pradesh
460
Cross-sectional
15–18
2011
Rotterdam
9.13%
Nidhi et al.
South
Kerela and Kottayam
200
Cross-sectional survey
18–31
2013
Rotterdam
15%
Vijan and Sonia et al.
South
Nellore (Andhra Pradesh)
80
Cross-sectional
19–35
2012–14
Rotterdam
15.4%
Akumar et al.
West
Mumbai
778
Cross-sectional
15–24
2014
Rotterdam
AES
22.5%
10.7%
Beenajoshi et al.
6Shweta et al. conducted a study in Tamil Nadu and concluded that the proportion of participants diagnosed with PCOS was higher among urban participants in comparison to rural participants.10 The prevalence of obesity, overweight, and insulin resistance, associated with PCOS pathogenesis, appear to be higher among members of higher socioeconomic strata living in urban areas; medical researchers have attributed this to more sedentary lifestyles and access to more calorie-dense foods and labor-saving devices in urban and higher socioeconomic populations.11 Gill et al. calculated that prevalence of PCOS in women between the ages of 18 years and 25 years from Lucknow, north India, is 3.7%. Majority of these girls were lean but have abdominal obesity.12 Nidhi et al. prospectively studied 460 girls aged 15–18 years from a residential college in Andhra Pradesh, South India. The authors have reported a prevalence of PCOS in 9.13% of the adolescents.13 Williamson et al. reported that PCOS women of different ethnicity presented with different clinical manifestation of PCOS.14 Studies conducted on Indian PCOS women suggested that abnormalities of the insulin receptor are more common in Indian women with PCOS compared to white women with PCOS.15 The prevalence of PCOS in Nellore district is 15.4%. Several factors influencing the occurrence of this syndrome have been investigated earlier.16 Beena Joshi et al. tried to look at the prevalence using both the Rotterdam and Androgen Excess Society (AES) criteria and concluded the prevalence of PCOS in Mumbai was 22.5% by Rotterdam and 10.7% by criteria. This indicates that the disorder is better picked up if the ASRM/ESHRE criteria are used. Non-obese comprised 71.8% of PCOS diagnosed by Rotterdam criteria. Mild PCOS (oligomenorrhea and polycystic ovaries on USG) was the most common phenotype (52.6%). The prevalence of PCOS depends on the choice of diagnostic criteria. They demonstrated that PCOS is an emerging disorder during adolescence and screening could provide opportunity to target the group for promoting healthy lifestyle and, early interventions, to prevent future morbidities.1
 
Metropolitan Cities
In 2000, a multicentric study involving six urban cities (Chennai, Bengaluru, Hyderabad, Mumbai, Kolkata, and New Delhi) in India among the age group of 20–40 years indicated that the prevalence rate of obesity was 31%. Our study showed a 37.5% prevalence rate of obesity in women with PCOS.16 A national survey of diabetes and IGT conducted in 2000 AD in six major cities of India showed a 13.1% prevalence of IGT and 5% prevalence of diabetes in the younger age group (20–40 years) of the general population.17
 
REASONS FOR RISING NUMBERS
A recent editorial by Aziz et al.2 challenges the view that the incidence of the disorder is rising but, at the same time, recognizing this enigmatic disorder has a genetic predisposition and is, therefore, being passed on down the generations. An error in the insulin metabolism leading to hyperinsulinemia and hyperandrogenemia has been attributed to it. There are, however, no reports to compare the incidence of the disease in the past centuries with the present and it is probably because of better recognition and definition of diagnostic criteria that the syndrome is better recognized and diagnosed. The reasons have been 7attributed to this sudden explosion of PCOS are obesity, changing lifestyle and environmental toxins. However, an mentioned above,2 published prevalence studies from many countries do not find a higher incidence of PCOS in the obese population thus giving credence to the fact that the disorder affects only those who have a genetic predisposition to the disorder.18
India has been labeled as the ‘diabetic capital of the world’ due to an alarming increase in the number of cases of both diabetes and metabolic syndrome. Since PCOS is a disorder of insulin metabolism, it is possible that there may be an increasing number of cases of PCOS as well. Further studies are warranted, especially from India, to know whether the incidence is rising or not, and what are the contributing factors.
REFERENCES
  1. Joshi B, Mukherjee S, Patil A, Purandare A, Chauhan S, Vaidya R. A cross-sectional study of polycystic ovarian syndrome among adolescent and young girls in Mumbai, India. Indian J Endocrinol Metab. 2014;18(3):317–24.
  1. Aziz R, Marin C, Hoq L, Badamgarav E, Song P. Healthcare-related economic burden of the polycystic ovarian syndrome during the reproductive lifespan. J Clin Endocrinol Metab. 2005;90:4650–8.
  1. Ganie MA, Kalra S. Polycystic ovarian syndrome – A metabolic malady, the mother of all lifestyle disorders in women – Can Indian health budget tackle it in future? Indian Journal of Endocrinology and Metabolism. 2011;15(4):239-41. doi:10.4103/2230-8210. 85571.
  1. Hanson AE. Hippocrates: diseases of women. Signs (Chic). 1975;1:567–84.
  1. Sharma PV. Charaka Samhita (English Translation) Chaukambha Orientalia. Varanasi: 1981.
  1. Srikantha Mruthi KR. Sushruta Samhita (English Translation) Chaukambha Orientale. Varanasi: 2001. pp. 170-3.
  1. Kar S, et al. Anthropometric, clinical, and metabolic comparisons of the four Rotterdam PCOS phenotypes: A prospective study of PCOS women. Journal of Human Reproductive Sciences. 2013;6(3):194–200.8
  1. Shabir I, Ganie MA, Zargar MA, Bhat D, Mir MM, Jan A, Shah ZA, Jan V, Rasool R, Naqati A. Prevalence of metabolic syndrome in the family members of women with polycystic ovarian syndrome from North India. Indian J Endocr Metab. 2014;18:364–9.
  1. Malik S, Jain K, Talwar P, Prasad S, Dhorepatil B, Devi G, et al. Management of Polycystic ovarian syndrome in India. Fertil Sci Res. 2014;1:23–43.
  1. Balaji S, Amadi C, Prasad S, BalaKasav J, Upadhyay V, Singh AK, Surapaneni KM, Joshi A. Urban Rural Comparisons of Polycystic ovarian syndrome Burden among Adolescent Girls in a Hospital Setting in India. BioMed Research International. Volume 2015. Article ID 158951.
  1. Pathak G, Nichter M. Polycystic ovarian syndrome in globalizing India: An ecosocial perspective on an emerging lifestyle disease. Social Science and Medicine 2015;146:21-8.
  1. Nidhi R, Padmalata V, N Gagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian adolescents. J Pediatr Adolesc Gynecol. 2011;24:223–7.
  1. Williamson K, Gunn AJ, Johnson N, Milsom SR. The impact of ethnicity on the presentation of polycystic ovarian syndrome. Aust NZJ Obstet Gynaecol. 2001;41:202-6.
  1. Norman RJ, Mahabeer S, Masters S. Ethnic differences in insulin and glucose response to glucose between white and Indian women with polycystic ovarian syndrome. Fertil Steril. 1995;63:58–62.
  1. Nagaraja Bhuvanashree, Sandhya Gupta, Medabalmi Anitha. Epari Venkatarao. Annals of tropical health and medicine. 2013;6(6):632–6.
  1. Snehalatha C, Ramchandran A, Kapur A, Vijay V. Age-specific prevalence and risk associations for impaired glucose tolerance in urban southern Indian population. J Assoc Physicians India. 2003;51:766–9.
  1. Holte J, Gennarelli G, Berne C, Bergh T, Lithell H. Elevated ambulatory daytime blood pressure in women with polycystic ovarian syndrome: A sign of a prehypertensive state? Hum Reprod. 1996;11:23–8.