PCOS is one of the most common endocrine disorders in women of reproductive age, often complicated by chronic anovulatory infertility and hyperandrogenism with the clinical manifestations of oligomenorrhoea, hirsutism, and acne. Many women with this condition are obese and have a higher prevalence of impaired glucose tolerance, type II diabetes and sleep apnoea than is observed in the general population. They exhibit an adverse cardiovascular risk profile, as suggested by a higher reported incidence of hypertension, dyslipidemia, visceral obesity, insulin resistance and hyperinsulinemia. PCOS is frequently diagnosed by gynecologists and it is therefore important that there is a good understanding of the long-term implications of the diagnosis in order to offer a holistic approach to the disorder.
Counselling :
Women should be made aware of the long-term implications of their condition, including their cardiovascular risk, by their doctor, in a way that is tailored to their individual circumstances. Women should be made aware of the positive effect of lifestyle modification, including weight loss, for improving their symptoms. Especially those women who are overweight or obese.
Risk of developing gestational diabetes in women with PCOS :
The prevalence of gestational diabetes mellitus is twice as high among women with PCOS compared to control women. Clinicians may consider offering a 2-hour post 75 g oral glucose tolerance test to all pregnant women with PCOS, similar as for screening in women with any other risk factors for gestational diabetes.
Should women with PCOS be screened for type II diabetes :
Insulin resistance is present in around 65–80% of women with PCOS, independent of obesity, and is further exacerbated by excess weight. Insulin resistance has been shown to worsen reproductive and metabolic features, type II diabetes and cardiovascular disease (CVD) risk in PCOS. Earlier onset hyperglycemia and rapid progression to type II diabetes are also reported in PCOS. PCOS is classified as a nonmodifiable risk factor for type II diabetes. Furthermore, type II diabetes is a major Cardiovascular risk factor, and lifestyle therapy has been shown to prevent or delay progression to type II diabetes. Hence early screening and identification in this high-risk group of women with PCOS are important.
Fasting blood glucose level alone has been shown to be inaccurate and results in underdiagnosis of type II diabetes in PCOS. Use of an HbA1c of 6.5% or greater has been proposed for the diagnosis of diabetes. However, caution should be exercised as patients with type II diabetes may be missed and the utilization of HbA1c for the diagnosis of diabetes in PCOS warrants better definition. Hence an oral glucose tolerance test is considered to be appropriate for screening women with PCOS for diabetes. However, it would be reasonable to carry out HbA1c measurements where women are unwilling to have oral glucose tolerance tests or where the resources are not readily available.
Risk of developing sleep apnoea in women with PCOS :
The prevalence of obstructive sleep apnoea is increased in obese women with PCOS. Androgen levels and insulin resistance are positively associated with obstructive sleep apnoea in PCOS.
Risk of developing cardiovascular disease (CVD) in women with PCOS :
All women with PCOS should be assessed for CVD risk by assessing individual CVD risk factors (obesity, lack of physical activity, cigarette smoking, family history of type II diabetes, dyslipidemia, hypertension, impaired glucose tolerance, type II diabetes) at the time of initial diagnosis.
Risk of having reduced health-related quality of life in women with PCOS :
Women with PCOS are at an increased risk of psychological and behavioral disorders as well as reduced quality of life (QoL). It has been shown that PCOS has a significant detrimental effect on QoL compared with controls and weight issues were most likely to affect QoL in women with PCOS. Women with PCOS are at a higher risk of developing psychological difficulties (such as depression and/or anxiety), eating disorders and sexual and relationship dysfunction.
Risk of cancer in women with PCOS :
Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma.
Strategies for reduction of risk :
Lifestyle management including diet, exercise and weight loss is recommended as the first line of treatment for women with PCOS; these changes should precede and/or accompany pharmacological treatment. In women with PCOS and excess weight, a reduction of as little as 5% of total body weight has been shown to reduce insulin resistance and testosterone levels as well as improving body composition and cardiovascular risk markers
Lifestyle management targeting weight loss (in women with a BMI of 25 kg/m2 or more [overweight/obese]) and prevention of weight gain (in women with a BMI of 18.5–24.9 kg/m2 [lean]) should include both reduced dietary energy (caloric) intake and exercise. This should be the first-line therapy for all women with PCOS for managing long-term consequences. Prevention of weight gain should be targeted in all women with PCOS through a monitored caloric intake and in the setting of healthy food choices, irrespective of diet composition. Behaviour change techniques should target prevention of weight gain in all women with PCOS. Women who have failed to lose weight with lifestyle strategies and who have a BMI of 40 kg/m2 or more or who have a BMI of 35 kg/m2 or more together with a high-risk obesity-related condition (such as hypertension or type II diabetes) should be considered for bariatric surgery
Specialist Obstetrics and Gynaecology
Aster Clinic, Dubai Silicon Oasis
