Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women. It is characterised by anovulation, hyperandrogenism and morphologically polycystic ovaries. The term itself was introduced more than 60 years ago and was coined based on the appearance of the ovaries. More on PCOS is brought to you by our dear associate Ana Vrbanović, MD.
In a polycystic ovary follicles do not grow to maturity. Due to the imbalance in hormone levels there is no selection or domination of follicles which is why anovulation occurs. Women with anovulatory cycles have a lower chance of pregnancy. Hyperandrogenism is characterised by elevated testosterone and androstenedione levels which causes hirsutism (excessive hairiness) and acne. 60% of women with this syndrome also has problems with obesity. The central disorder is in the theca cell function in the ovary which leads to increased steroidogenesis (androgen synthesis).
Androgens and oestrogens are steroid hormones. They are synthesised in the androgen glands, ovaries, testicles, placenta and the brain. In addition to having sexual functions, they have various effects on the skin. In the skin androgens regulate growth of hair and the production and secretion of sebum. They also partake in wound healing and skin barrier synthesis.
The sebaceous gland is located in the skin and synthesizes a mixture of lipids commonly known as sebum. One of the four main causes of acne is increased sebum production. Androgen receptors are located on the sebaceous gland and its main function is to stimulate gland growth and differentiation which in turn increases secretion of lipids. This leads to clogged pores, comedones and acne. If the sebum-feeding bacteria Propionibacterium acnes are also present, acne will become inflamed. They become red, painful, warm to the touch and raised.
In the hair follicle androgen receptors stimulate hair growth. Many long-lasting hair strands such as those on the scalp, eyebrows or eyelashes are created at birth and have a protective role. Other hairs are part of secondary sexual characteristics and start growing in puberty as a response to raised androgen levels in the blood. In the case of increased androgen levels as in PCOS, excessive hairiness appears in places which are typically hairy in men. Nevertheless, women with PCOS have normal oestrogen levels and normally developed secondary sexual characteristics.
One of the fundamental hormonal and metabolic disorders in PCOS patients is abnormal insulin activity. Insulin resistance appears, in turn leading to hyperinsulinemia. In adipose women the abnormality is even more pronounced. Increased insulin levels affect theca cells and cause an increase in androgen production directly intensifying the function of enzymes for steroidogenesis. Also, it reduces sex hormone binding globulin and thereby creates an excess of free testosterone accompanied by all peripheral effects of hyperandrogenism. Adipose women with PCOS and insulin resistance have a significantly higher level of testosterone, androstenedione, higher free androgen index and consequently, more pronounced hirsutism and acne. Raised androgen concentrations also distribute fatty tissue towards abdominal obesity.
A PCOS diagnosis is made based on a combination of clinical, ultrasound and biochemical findings. Among clinical symptoms, disruption of the menstrual cycle appears (oligo amenorrhea or amenorrhea – reduced or complete absence of menstrual bleeding) and hirsutism. A transvaginal ultrasound is used to check for symptoms: increased volume of the ovaries, follicles arranged in a necklace like pattern and a thick stroma. Of course, if there is reason for suspicion, hormonal status must be checked as well as lipoprotein and triglyceride levels and insulin. There are five main methods for treating patients with PCOS. Weight loss is one of the most important ones. Weight reduction in as little as 5% may lead to an ovulation cycle. Weight loss also leads to a decrease in androgen levels while the sensitivity of sex hormone binding globulin increases. The second method is to intensify physical activity and the third to stop smoking and drinking alcohol. In addition to these methods, pharmacological and surgical approaches are also used. Birth control pills are one of the first choices. They inhibit steroidogenesis in the ovary. As far as surgical methods go, ovarian wedge resection and electrocauterisation are used. The surgical treatment on its own gives satisfactory results. However by application of antiandrogen in 30 to 40% of the women the symptoms quickly reappear. That is why reducing body weight and fatty tissue are the best solutions.
As far as local treatment goes, proper cleansing is recommended to remove excess sebum and prevent pores from becoming clogged. That is why acne treatments include acids such as salicylic acid to remove dead skin cells and dissolve excess sebum. This reduces the possibility of development of comedones. Squeezing and picking on spots should also be avoided because when doing so, bacteria are transferred to other parts of the face.
REFERENCES:
- Azziz R, Carmina E, Chen Z, Dunaif A, Laven JS, Legro RS, Lizneva D, Natterson-Horowtiz B, Teede HJ, Yildiz BO. Polycystic ovary syndrome. Nat Rev Dis Primers 2016; 2:16057.
- Randall, V.A., Androgens and human hair growth. Clin Endocrinol (Oxf), 1994. 40(4): p. 439-57.
- Strauss, J.S.P., P.E., The hormonal control of human sebaceous glands, in Biology of Skin. The sebaceous glands, E.R. Montagna W, Silver AF, eds, Editor. 1963: Oxford: Pergamon Press. p. 220-254.
