An ovulation, androgen excess and polycystic ovarian morphology in ultrasound assessment are the three main criteria that fit the diagnosis of PCOS. Though it is understood that most attention of the clinicians has to be paid to the management of specific symptoms linked to PCOS, it is important to attend to the complexity of the syndrome leading to a number of metabolic and other implications of women’s health. PCOS is an endocrinopathy with a long prodrome phase manifesting detectable abnormalities throughout the life cycle of affected women. Women with PCOS are at increased risk for impaired glucose tolerance, hypertension, coronary artery disease and cancer. It is not certain that all women with PCOS will develop these conditions, but having PCOS increases health risks.
Evidence demonstrates that the prevalence of type 2 diabetes in women diagnosed with PCOS is 7 times higher than in controls. The presence of a defect in insulin action which amplifies Luteinising Hormone (LH) stimulated androgen secretion from thecal cells of the ovary has been well established. Insulin resistance appears to be the key underlying abnormality that leads to later development of impaired glucose tolerance. About 60% of women with PCOS are reported to be obese. The central distribution of fat in women with PCOS is not dependent to BMI but actually is associated with higher insulin concentration. Independent of obesity, it is reported that more than 20% of obese women with PCOS will have impaired glucose tolerance after the age of 30. Insulin resistance combined with abdominal obesity is thought to account for the higher prevalence of type 2 diabetes in PCOS. However, the risk of developing type 2 diabetes is also increased in non-obese women with PCOS and this makes PCOS an independent risk factor for type 2 diabetes in middle age. The risk is observed to be much greater in women with PCOS who are also obese and who need ovulation induction in order to conceive.
Coronary artery disease
Women with PCOS are also diagnosed with extensive coronary artery disease. Impaired glucose tolerance and diabetes caused by PCOS are known risk factors for cardiovascular disease. Direct atherogenic action and lipoprotein adverse effects are the two mechanisms of insulin resistance in PCOS which contribute significantly to higher incidence of cardiovascular disease in these women. The lipoprotein profile in women with polycystic ovaries is significantly distorted. They usually have high concentrations of serum triglycerides and low-density lipoprotein cholesterol whereas the levels of high density lipoprotein (HDL) are suppressed. In addition, elevated levels of serum plasminogen could directly affect vascular tissue causing atherogenic changes associated with coronary heart disease. There is scientific data results that prove that there is indeed an increased risk for women with PCOS of developing cardiovascular disease.
There seems to be a direct relationship between insulin plasma levels and blood pressure in women with PCOS. Insulin resistance, hyperandrogenism, greater sympathetic nerve activity and concomitance of obesity are stressed as the main causes of hypertension in PCOS women. Obese conceived women with PCOS are reported with increased incidence of preeclampsia than the general pregnant population. The prevalence of treated hypertension is much higher in women with PCOS between the age of 40-59 years. High blood pressure is a leading cause of heart disease and stroke in later years of women with PCOS. Because PCOS may contribute to earlier development of hypertension as well as pre-hypertension it is advisable to monitor blood pressure systematically so as to control known risk factors and to initiate the treatment of hypertension when the disease occurs.
Long term risks of PCOS are also focused on its possible associations with endometrial cancer. Prolonged anovulation which characterizes the syndrome is considered to be the main mechanism responsible for continual unopposed secretion of oestrogens and consequent increased risk of endometrial carcinoma. Other symptomatic PCOS related factors that might increase the risk of developing endometrial cancer are obesity, long term use of unopposed oestrogens, nulliparity, infertility, hypertension and diabetes. In women with PCOS intervals between menstruation of more than three months may be associated with endometrial hyperplasia which may be a precursor to adenocarcinoma. Evidence from a big study reveals that excess risk of endometrial cancer is identified with anovulation.
Women with PCOS are expected to be in low risk groups for developing ovarian cancer due to their life time reduced ovulation rate but using ovulation induction treatments can theoretically create technical imbalance to their risk for ovarian cancer. The risk appears to be increased in nulliparous women with drug induced multiple ovulations, with early menarche and late menopause There are only a few studies that have addressed the possibility of association of polycystic ovaries with ovarian cancer and have revealed conflicting evidence. There are debates and concerns about the risk of ovarian cancer in women with anovulation and association between polycystic ovarian syndrome and ovarian malignancy are still conflicting.
There is a positive association between PCOS and the presence of family history of breast cancer whereas studies failed to show any significant increase in the risk of developing breast cancer in women with PCOS. Obesity, hyperandrogenism and infertility that are common features in PCOS may be associated with the development of breast cancer.
It is estimated that one in three women with PCOS have metabolic syndrome. Associative features include insulin resistance, high blood sugar, obesity, high cholesterol and high blood pressure. This syndrome occurs when the body is not able to balance all the chemicals and processes it needs to create and use energy. Metabolic syndrome increases the risk for diabetes and heart disease.
Obstructive sleep apnoea
Women with PCOS are at much higher risk for obstructive sleep apnoea than other women. This risk is even higher among women with PCOS who are obese. Obstructive sleep apnoea is the condition caused by narrowing of airway during sleep. While sleeping, the muscles that keep the airways open, relax and result in narrow or closed airways. This may stop breathing for several seconds and causing a snorting or choking sound when able to breathe again. Sleep apnoea can increase the risk of high blood pressure, heart attack, obesity and diabetes.
All women with PCOS may not necessarily develop these conditions, but having PCOS increases the risk. Therefore it is important to insist on regular monitoring of health from gynaecologists experienced in treating women with PCOS. Even though there will be no erratic periods and other PCOS symptoms may lessen after menopause, changes caused by altered mechanism of PCOS can pose health risks during pre and post-menopausal years. Medical check-ups throughout the reproductive years and continued after menopause will keep women with PCOS safe from associated health risks.