Ultrasound studies and PCOS

Example: "My daughter has severe acne. She has also recently gained a lot of weight. Why is the dermatologist asking her to get an ultrasound done? What is the connection? I am worried about this."

Discussion:
The girl above has severe acne and a history of weight gain. These are two common symptoms in a person with Polycystic Ovarian Syndrome or PCOS. It is likely that the ultrasound was recommended to screen for PCOS, wherein the ovaries may show multiple small cysts. However, not all patients with these symptoms have PCOS and not all patients with PCOS show these symptoms or have any changes in the ultrasound. Thus the ultrasound is only part of the PCOS work up and must be correlated clinically with history and examination.

Multiple small cysts seen in the ovary around a dense pattern, called the 'String or Pearls' sign which indicates the presence of PCOS in the individual. It however is only one sign of PCOS and does not dictate all the symptoms of the person.

One must not be unduly concerned about being asked to undergo an ultrasound and should discuss the above with the dermatologist/treating physician. If the doctor is considering PCOS as a diagnosis they may also recommend various blood tests and a detailed menstrual history along with the ultrasound to gain a complete picture. With a complete diagnosis, it would be possible to offer a far superior and more effective treatment for all concerns.

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ULTRASOUND CRITERIA FOR MAKING A DIAGNOSIS OF PCOS:

PCOS does not have a single definitive picture but occurs as a cluster of symptoms and signs. Women with the condition may have all/some/none of the symptoms associated with PCOS with or without ultrasound evidence of PCOS. Several studies have highlighted that the criteria used to establish the diagnosis of PCOS remain controversial. The revised diagnostic criteria proposed in 2003 at the Rotterdam European Society of Human Reproduction and Embryology/American Society of Reproductive Medicine consensus workshop stated ultrasound polycystic ovarian morphology (PCOM) be necessary to establish the diagnosis of PCOS. A recent study funded by Cornell University noted that the existing Rotterdam criteria for diagnosis of PCOS using did not adequately and specifically cater to all groups of women with PCOS.

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Bibliography:

1. Hum Reprod. 2013 May;28(5):1361-8. doi: 10.1093/humrep/det062. Epub 2013 Mar 15. Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume. Lujan ME, Jarrett BY, Brooks ED, Reines JK, Peppin AK, Muhn N, Haider E, Pierson RA, Chizen DR.

2. Semin Reprod Med. 2008 May;26(3):241-51. doi: 10.1055/s-2008-1076143. Polycystic ovary syndrome: the controversy of diagnosis by ultrasound. Porter MB.

3. J Obstet Gynaecol Can. 2008 August; 30(8): 671–679. Diagnostic Criteria for Polycystic Ovary Syndrome: Pitfalls and Controversies. Marla E. Lujan, Donna R. Chizen, Roger A. Pierson

4. J Hum Reprod Sci. 2013 Jul;6(3):194-200. doi: 10.4103/0974-1208.121422. Anthropometric, clinical, and metabolic comparisons of the four Rotterdam PCOS phenotypes: A prospective study of PCOS women. Kar S.

Dark Patches in Patients with PCOS

Uneven, velvety patches of darkened and thickened skin may be seen on certain areas on the skin of individuals with PCOS. It occurs in areas with skin folds and is most commonly seen on the back of the neck, under arms and groin. The skin in these areas appears warty, thick and brown to black to grey.

This condition is termed Acanthosis Nigricans or AN (Acanthosis means an abnormal thickening of the skin, while Nigra implies darkness.) AN is not a diagnostic symptom of PCOS, as AN occurs due to a wide variety of causes; hormonal imbalance like that seen in PCOS is merely one of them. However, the finding is significant in women with other symptoms of PCOS as it signals insulin resistance. The appearance of unsightly dark patches may first prompt an individual to seek medical attention and undergo evaluation. AN is cosmetically unpleasant and often becomes a gateway to further discussion regarding PCOS during a dermatological consult. 

Remedies for AN in patients with PCOS:

1. The underlying cause of AN must first be determined and treated appropriately. Obesity, hormonal imbalance (such as Cushing's syndrome or PCOS), family tendency or rarely tumours elsewhere in the body may cause AN. In women with PCOS, AN signals the presence of insulin resistance. 

To correct this underlying insulin resistance the patient may be treated with medication such as metformin or with newer supplements containing n-Acetyl Cysteine and alpha lipoic acid. In addition it is important to maintain an active lifestyle with regular exercise and to follow a balanced diet incorporating leafy vegetables while limiting intake of sugary processed foods and high glycemic index foods, principles which are common to all individuals with PCOS.

2. Gentle resurfacing of skin with chemical peels or mild microdermabrasion in conjunction with topical medication (preparations containing urea and salicylic acid) gives good results. 

The Biology of PCOS: Simplified

Polycystic Ovarian Syndrome is the commonest hormonal imbalance in women across the world. 

Although the name suggests the presence of cysts in ovaries of all those affected, this is simply not true. The syndrome causes a cluster of symptoms and any affected person may have none, one or more symptoms in any combination. 

The syndrome mainly does three things, which have a complex cause-effect relationship with the other:

1) Resistance of cells to the effect of the hormone Insulin, which causes disturbance of digestion of sugars. This in turn can cause diabetes and storage of eaten sugars as fat. Insulin resistance contributes to acne, weight gain and other symptoms.

2) Excessive production of male hormones or androgens in the female body, which is exaggerated in the presence of excess fat, especially around the abdomen. The presence of excess amounts of male hormones causes unwanted facial and body hair, acne and hair loss from the scalp.

3) The disturbance of hormone profiles is in turn associated with a disruption of the normal menstrual cycle. The usual process of ovulation is interrupted, causing anovulatory cycles, which further changes the pattern of secretion of male and female hormones in the body. 

Problems in conception, irregularities of timing, heavy painful periods and cramps may or may not be seen in these anovulatory cycles. 

Keeping the above in mind, some experts opine that 'Anovulatory Androgen Excess' is a better terminology than PCOS for this condition. Research shows that despite the common occurrence of the syndrome, up to fifty percent of women with PCOS are not aware of their diagnosis. Thus it is imperative to work towards creating an increased awareness of the symptoms, as well as acceptance of the diagnosis and instillation of hope in women exasperated by these seemingly disconnected and vague symptoms. 

PCOS is a challenge that can easily be vanquished with appropriate lifestyle modification and treatment. To this end, PCOS Initiative aims to work towards providing support and education about this condition, to help women take charge of their own well-being, and overcome the impact of PCOS on their lives. We choose to focus on the cosmetic changes of PCOS, namely the changes in skin, hair and body weight, which can the affect the self-esteem of affected women and in some cases also their personal and professional lives. 

What Causes PCOS:

The exact cause of PCOS remains a subject of research. A number of factors have been identified which influence the appearance and course of the condition.

Image: Teede et Al, BMC Medicine 2010

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Image: Rotstein, Srinivasan and Won

Not all patients with PCOS would have evidence of cysts in the ovaries on ultrasound, just as not all of them would have all the skin/hair/fertility/weight/period related symptoms of PCOS.

Where do the androgens come from?

Androgens or male hormones are produced in the ovaries, due to a disturbance in ovulation.

Image: utendocrinology.com

Image: Hector F, Escobar-Morreale

Image: Implementdesignism.org

What is Insulin Resistance?

Insulin is a hormone produced by the pancreas in our body. Insulin Resistance means that the tissues of an individual are resistant to the action of insulin. The major action of insulin is to digest glucose or sugar. Thus, simply put, Insulin Resistance means that a person is unable to digest sugar properly, leading to various symptoms, and storage of sugar as fat.

Image: singhealth.com

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Disclaimer

The author does not accept any liability to any person for the information or advice (or use of such information or advice) which is provided on this page or incorporated into it by reference.  
This information is not intended to be medical advice/opinion. It is provided with the understanding that all persons accessing it take responsibility for assessing its relevance & accuracy. Readers are requested to discuss their specific health needs with their respective treating physicians.