PCOS management and successful treatment protocols

During this session, Dr Viktoria Mokhnii, Gynaecologist & Reproductologist at The Ekstramed Reproductive Medicine Clinic, discussed effective PCOS management and treatment strategies. Dr Mokhnii explained the underlying causes, symptoms, and how it affects women’s health.

Polycystic Ovary Syndrome (PCOS) is a complex and multifactorial endocrine and metabolic disorder with lifelong complications related to female infertility and social imbalance. PCOS is characterized by chronic anovulation, menstrual cycle irregularity, infertility, obesity, insulin resistance, polycystic ovaries, hyperandrogenism, hormonal abnormalities, depression, and impaired mitochondrial health. Understanding the pathophysiology and treatment of PCOS is essential for providing effective care to affected individuals.

PCOS has a multifactorial and heterogeneous pathophysiology, involving a vicious cycle of complex disorders. Hyperandrogenism and a predisposition to insulin resistance play pivotal roles in the development of this syndrome. Genetic, neuroendocrine, and metabolic causes contribute to transgenerational components, putting daughters born to mothers with PCOS at a fivefold higher risk. Recent studies suggest that dysbiosis of gut microbiota may be a potential pathogenic factor in PCOS development.

PCOS manifests with a range of clinical features, including irregular menstruation, obesity, acne, oily skin, chronic low inflammation, immunological dysregulation, metabolic syndrome, hormone imbalance, and more. Anti-Müllerian hormone (AMH) levels serve as a valuable predictor for PCOS diagnosis, and high LH pulsatility and elevated androgen levels are common.

Classification of PCOS

PCOS is classified into four types based on clinical characteristics:

• Classical PCOS: Symptomatic hyperandrogenism, ovarian dysfunction, and high metabolic dysfunction in polycystic ovaries.
• Type B PCOS: Symptomatic hyperandrogenism, ovarian dysfunction, high metabolic dysfunction, but normal ovarian morphology.
• Type C PCOS: Non-classic, with symptomatic hyperandrogenism, regular periods, moderate metabolic dysfunction, and polycystic ovaries.
• Type D PCOS: Non-classic and non-hyperandrogenic, with normal androgens, ovarian dysfunction, minimal metabolic dysfunction, and polycystic ovaries.

PCOS – various factors

Chronic low-grade inflammation is strongly associated with PCOS, driven by factors like hyperinsulinemia and obesity. Inflammatory markers such as C-reactive protein, interleukin-18, tumor necrosis factor-alpha, and others can aid in the diagnosis of PCOS.

Insulin resistance, hyperinsulinemia, and hormonal imbalances are fundamental factors in PCOS pathogenesis. Dysregulation of the hypothalamus-pituitary-ovary axis contributes to the development of PCOS, leading to increased LH synthesis over FSH synthesis and promoting androgen synthesis in ovarian theca cells.

Recent research highlights a connection between gut microbiota dysbiosis and PCOS development. Dysregulated gut microbiota can disrupt host microbial balance, contributing to the development of PCOS and type 2 diabetes.

Obesity significantly impacts PCOS management, as it extends the time to pregnancy and exacerbates ovulatory dysfunction, insulin resistance, and androgen production.

Treatment protocols

PCOS treatment focuses on symptom management and individualized care. Weight management through lifestyle modifications, including a low-carb diet and exercise, plays a crucial role. Nutritional supplements like vitamins, minerals, and probiotics can help improve metabolic and reproductive health.

Real-life cases

• a 25-year-old woman weighing 82 kg has been experiencing irregular menstruation since the age of 15 and has not ovulated

Her ovaries’ volume was elevated, measuring 13 and 15, whereas the normal volume should be around 10. Sonographic evidence suggested Polycystic Ovary Syndrome (PCOS). Her endometrial thickness was less than optimal. Her oral contraceptive use, thyroid test results, and hormone levels were within a normal range, but basal estradiol was slightly lower at 20. Notably, her free testosterone level was significantly elevated at 625, with a high free Androgen index of 9.2. She also exhibits elevated levels of lipoproteins and cholesterol. A hysteroscopy revealed signs of chronic endometritis, characterized by red spots and increased vascularity in the endometrium. This inflammation could impede pregnancy.

Treatment protocol

In response to this diagnosis, a comprehensive treatment protocol was developed. It started with anti-inflammatory treatment targeting the uterine cavity, considering the microbiota. Anti-androgen therapy was initiated to reduce the elevated free testosterone levels and improve endometrial receptivity.  A total of five high-quality blastocysts were obtained and frozen. The treatment approach followed the Freeze-All method, which is commonly utilized in PCOS protocols. Hormonal replacement therapy was employed, combined with a low-carb diet and exercise regimen, that resulted in a 5-kilogram weight loss within two months. The patient was prescribed myo-inositol at 2 milligrams daily, vitamin D at 5,000 international units daily, probiotics at 400 MCG daily, selenium at 200 MCG daily, coenzyme Q10 at 200 milligrams daily, and magnesium at 200 milligrams daily. This multidimensional treatment approach led to a successful pregnancy within 4 months.

The relationship between chronic endometritis and PCOS was emphasized during treatment. Insulin resistance was identified as a key factor affecting endometrial function. Hyperinsulinemia contributes to inflammation and interferes with the normal periodic shedding of the endometrium. Insulin resistance, often associated with obesity and low-grade inflammation, disrupts the endometrium in PCOS patients. Successful treatment strategies aim to restore endometrial health by addressing insulin resistance, optimizing hormonal balance, and promoting good-quality embryos for implantation.

• a 23-year-old woman weighing 67 kg has experienced irregular menstruation since the age of 16 and has not ovulated, the volume of her ovaries was significantly increased, measuring 123. Sonographic evidence suggested PCOS, with her endometrium displaying signs of inflammation

Her oral contraceptive use, menstrual cycle, Inhibin B levels, thyroid test results, prolactin, basal estradiol, and free testosterone levels are within normal ranges. However, her total testosterone level is slightly elevated at 325. A hysteroscopy diagnosed chronic endometritis, accompanied by the presence of a uterine cavity polyp.

Treatment protocol

The patient received a targeted treatment protocol designed to address the specific issues identified. Treatment included the removal of the uterine cavity polyp through hysteroscopy, followed by an anti-inflammatory regimen for the uterine cavity. Anti-androgen therapy was initiated to optimize endometrial quality, and hormonal balance was restored to improve the chances of successful implantation. The patient was prescribed myo-inositol at 2,000 international units daily, vitamin D3 at 5,000 international units daily, selenium at 200 MCG daily, vitamin E at 400 milligrams daily, probiotics at 400 MCG daily, coenzyme Q10 at 200 milligrams daily, and magnesium at 200 milligrams daily. This comprehensive treatment plan, combined with IVF, resulted in a successful pregnancy within 5 months.

Conclusions

In conclusion, the treatment and management of Polycystic Ovary Syndrome (PCOS) are essential for women’s health and well-being. PCOS is a complex endocrine disorder that affects metabolic, reproductive, and psychological functions. It is crucial to accurately diagnose and promptly treat this condition, considering each patient’s unique needs and desires, whether they aim to conceive or simply improve their overall health. Listening to and understanding patients’ concerns is vital in delivering effective care and achieving positive outcomes.