September Issue 2010

Growing up, Tanya experienced things that most teenage girls do: mood swings, irregular menstrual cycles, occasional bouts of acne and a perpetual struggle to manage her weight. Every so often, her frustration landed her at the doorstep of a new doctor in a quest to seek relief from her never-ending problems. But each time, she was sent home with a new prescription for hormonal drugs and the reassurance that her symptoms were common for girls her age. “The doctors always reassured me that such problems usually balanced out with time. But as I grew older, my problems became more bothersome and showed no signs of leaving,” she says.

Eventually, at age 21, Tanya’s desperation led her to yet another doctor — only this time, the doctor had a very different reaction to her problems. “Your persistently irregular menstrual cycle is a clear indicator that this is a case of Polycystic Ovarian Syndrome (PCOS),” she was told. “We’ll need to do some blood tests and an ultrasound to confirm this, but it’s very common nowadays and I can’t believe that no other doctor has given you this diagnosis before!” Simultaneously relieved and concerned about the implications of this condition, Tanya embarked on a mission to learn more about this syndrome, and redeem her self-image which had suffered over the years. In fact, PCOS is a health issue all Pakistani women need to learn more about.

PCOS is a condition where multiple small cysts form on a woman’s ovaries causing a hormonal imbalance that subsequently leads to other health problems. “It is a very common syndrome all around the world and affects a significant percentage of women of childbearing age,” explains Dr Nighat Khan, a gynaecologist who specialises in the study of PCOS and runs a private clinic in Zamzama, Karachi. “More and more women are being diagnosed with this condition, and it is important that it is identified at an earlier rather than at a later stage, when it becomes more difficult to reverse and may adversely affect [a woman’s] fertility.”

But identifying PCOS isn’t always a straightforward task. Like in Tanya’s case, the symptoms are initially considered typical for a normal, growing girl. It is only when the problems persist that a girl should start getting worried. “Almost every woman struggles with irregular periods at least once during her reproductive years. But if you are continually struggling with them alongside experiencing a number of other symptoms, you might actually be suffering from this disorder, in which case it becomes important to seek treatment,” says Dr Khan. While there is no concrete way of identifying PCOS, there are a number of indicators, external and internal, that can help detect it.

External symptoms generally vary from person to person, but the most common ones include irregular menstrual cycles, obesity, acne, hairloss, hirsutism (the excessive growth of hair on the face, chest, abdomen, etc.) and infertility or reduced fertility. Some women may experience all these symptoms, while others may experience nearly none. Internal indicators are often derived from blood reports and ultrasounds. Besides blood tests that measure levels of testosterone and prolactin, one specific blood test checks the ratio of LH (luteinising hormone) to FSH (follicle stimulating hormone). A large discrepancy in this ratio is a vital indicator of PCOS. Monitoring the ovaries through ultrasounds is also important to assess the incidence and size of cysts. But no matter how many or how few symptoms are evident, it is important to address the matter in its early stages as it later gives way to other serious problems such as cardiovascular disease, endometrial cancer, high blood pressure and the development of type 2 diabetes.

The relationship between PCOS and diabetes is something that is being given more attention in contemporary studies. “Recent research is pointing to insulin resistance present in women as a major cause-and-effect factor in the syndrome,” says Dr Khan. “Insulin resistance is when a person has trouble using insulin in the body properly, which effectually heightens the risk of PCOS sufferers becoming diabetic in the long run.” Excess insulin in the body is also found to be the most common cause of anovulation, the condition when a woman fails to ovulate regularly, thus making it imperative for PCOS sufferers to keep a regular check on their insulin levels.

Another cause of this disorder maybe a hereditary predisposition. “While it is not known if women are born with this condition, PCOS studies suggest that it seems to run in families,” says Dr Khan. It is not necessary, however, that all women with the genes will develop the condition. Furthermore, there is a higher likelihood of developing it if there is a family history of diabetes, or if there is early baldness in the men of the family. However, the evidence for genetic-related causes has been only vaguely substantiated by studies and requires more research.

Diet and lifestyle are other considerations that need to be closely regulated. “Since most PCOS patients are overweight, a healthy diet is of utmost importance for them. Not only should they watch the food they eat but they must also incorporate exercise into their routines — it is simply a must for them,” insists Dr Khan. “Nowadays, we don’t make time to eat proper meals and prefer to pick up food on the go. Such food is usually calorie dense, which is detrimental to PCOS patients.” One thing she strongly advocates not only for patients of this syndrome but also for everybody else is the importance of a good breakfast. “We have all heard it before, but I will say it a thousand times again: breakfast is vital for good health and a good lifestyle — do not leave home without it.” Dr Khan explains that in recent years, more and more women have enrolled in demanding educational programmes and office jobs, hence they have less time to incorporate a healthy diet and exercise regimen into their routine. “It may even be the reason for why PCOS seems to be more prevalent now than ever before,” she says.

As far as treatment options go, Dr Khan dispels the assumption that PCOS is ‘curable.’ “When a girl is diagnosed with PCOS, she must understand that there is no magical treatment for this syndrome. Instead of a single treatment, this syndrome requires long-term management, which means a combination of lifestyle changes in addition to hormone-stabilising medicine. While it requires a life-long commitment, it doesn’t mean it is hard to do; it just means better habits,” she explains. Aside from lifestyle modification, a practitioner’s first choice of allopathic treatment for women not looking to conceive is the oral contraceptive pill that contains a combination of oestrogen and progesterone hormones that regulate a woman’s menstrual cycle. Other allopathic medicines to regulate menstrual cycles include Metformin and Clomid. “Metformin, otherwise commonly known as Glucophage, is usually used to treat diabetes, but due to the connection between PCOS and insulin resistance, this medicine is also useful in increasing insulin sensitivity in PCOS patients,” says Dr Khan. On the other hand, Clomid is a medicine that is given to stimulate ovulation in women who want to conceive. “Often times, both of these are given to patients as a combination treatment.”

It is important to note here though, that once the menstrual cycle is regularised, all the other symptoms do not necessarily disappear. “Like I said, there is no magical cure for PCOS and all its symptoms. Each symptom will have to be addressed individually, and for that you might have to consult a host of specialists collectively.” Ideally, PCOS women should be seen by various physicians for the various components of the syndrome: a gynaecologist for their menstrual cycle and fertility qualms, a dermatologist for acne and hirsutism, an endocrinologist for insulin-resistance management and a nutritionist for dietary consultation. “Ideally, it would be wonderful to have a team dedicated to PCOS in a single centre like they have all over the world. Nobody has done much to initiate such a thing in Pakistan yet, but I have some plans involving this approach — hopefully sooner than later,” says Dr Khan.

Furthermore, PCOS patients may want to do more than consult medical doctors. “High levels of stress are also characteristic of such women and excess stress can lead to mood swings, low motivation, etc. Alternative therapies such as acupuncture, homeopathy, reiki and yoga may also be useful to reduce stress and perk up your motivation levels,” adds Dr Khan.

PCOS is a condition that is becoming common not only in Pakistan but also all over South Asia. “In fact, we are now realising that there seems to be a PCOS belt around all the South Asian countries, which includes the Middle East, Iran, Sri Lanka, Bangladesh, India and Pakistan. We don’t have in-depth data from this belt as yet as only minimum research has been done until now, but it could indicate that there is a strong correlation between diet, environment, genetics and PCOS,” offers Dr Khan. One particular study carried out by the University of Leeds, UK, on the women of Pakistani origin in the UK, found that compared to Caucasian women who had a PCOS incidence rate of 20-25%, Pakistani women had an incidence rate of 50%. “More studies are still being done, but we know for sure it is affecting a large majority of Pakistani women nowadays, and it is important that they know how to address it rather than ignore it.”