Obese girls could develop PCOS (above) and exercise might help

Girls change physically when they attain puberty, and most mature into attractive women. A few become unrecognisable. They become obese, develop acne and have hairy arms and legs. They sprout facial hair, develop a receding forehead and, if there is a familial tendency, male pattern baldness as well. This in itself is enough to make parents anxious. If, in addition, the periods are also irregular, scanty or excessive, parents often bring the girl for evaluation.

Most of these women have poly cystic ovarian syndrome (PCOS). This affects 10 per cent of the women in the childbearing assge group. In addition to the typical physical characteristics, an ultrasound shows multiple fluid filled cysts dotting the periphery of both ovaries.

The changes are due to a relative insulin resistance. These women show blood values of high fasting insulin levels of over 10 IU/mL (international units per millilitre), although 25-30 IU /mL is the cut off in men and older people.

The ovary responds to this high insulin level by producing more male hormones like testosterone. The brain responds by resetting the pituitary ovarian control axis and its chemical messengers. The eggs in the ovaries remain immature fluid filled sacs and are not released (anovulation). Anovulation, unbalanced hormones, irregular feedback from the brain, all these reasons cause irregular menstrual cycles, relative infertility and, later, recurrent pregnancy loss.

PCOS is genetic and probing questions will reveal relatives (male and female) with adult-onset diabetes, obesity, high values of triglycerides and high blood pressure. Many close female relatives may also be obese and hirsute, with menstrual problems and infertility.

Unfortunately, although many of these patients seek help during their late teenage years, they are not investigated or diagnosed properly.

They are offered placatory advice instead and given iron and calcium supplements. Some are given mysterious proprietary aryuvedic “gyno mix” tonics. Others are assured that the condition will spontaneously resolve itself after marriage.

Nothing could be further from the truth. Treatment and lifestyle changes have to be made to correct the cascading biochemical abnormalities.

Weight control is the mainstay of treatment. As far as possible, only 1500 — 2000 calories should be consumed a day (20 kcals/kg/day). Carbohydrates should be complex so that digestion and assimilation take time, increasing satiety. At least four helpings of fruits and vegetables should be eaten every day.

Dieting alone causes initial weight loss after which there is a plateau and then the weight starts to increase again. To sustain and maintain the correct weight, diet has to be combined with aerobic exercises like walking briskly, jogging or cycling for 45 minutes a day.

Medications like metformin,rosiglitazone and pioglitazone either singly or in combination correct the biochemical abnormalities. This is itself may regularise the cycles and restore regular ovulation.

Oral contraceptive pills (OCPs) provide oestrogen and progesterone in the correct proportions to artificially produce regular menstruation. The hirsutism and acne also decrease as the pills restore the hormonal balance. However, if the woman wishes to become pregnant, OCPs should be discontinued. Other medication like clomipheneor letrozole should be taken on the appropriate days under strict medical supervision.

Surgical treatment can be performed by expert and experienced doctors. Traditionally a “wedge resection” of the ovary was done and then ovulation was induced with medications. Now there are newer techniques. Each ovary can be drilled and punctured 10 -12 times through a laparoscopic puncture wound using a laser fibre or electrosurgical needle. This results in a dramatic lowering of male hormone levels in 80 per cent of cases within days. Many women who did not ovulate initially with letrozole or metformin therapy will do so after ovarian drilling. Interestingly, women who smoke, take snuff or chew tobacco rarely respond to the drilling procedure.

Once women with PCOS become pregnant, only half the battle is over. They are more prone to developing gestational diabetes, hypertension in pregnancy and have a poor outcome with abortion or still birth. If they have become pregnant after taking fertility medication, they are more likely to have multiple pregnancies, with twins or triplets.

As women with PCOS grow older, their menstrual cycles may become normal. They still remain at risk for diabetes and hyperlipidemia. Both these increase the risk for strokes and heart attacks. They are also at higher risk for uterine cancer. If you have PCOS, remember it can be controlled but not cured. Reduce your risk factors with diet and regular exercise. Keep your weight in the normal range and go for regular annual check ups to detect and reduce your risk factors.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in