Some patients may not be aware that they suffer from polycystic ovarian syndrome (PCOS), which leads to a delay in treatment. Pharmacists are uniquely positioned to educate patients about the condition and possible complications that may occur during pregnancy.
WHY PCOS PATIENTS ARE AT A HIGHER RISK FOR COMPLICATIONS DURING PREGNANCY
PCOS is a hyperandrogenic disorder associated with chronic anovulation and polycystic ovarian morphology, explained Dr Surendra Bisu and Dr Vinu Choudhary (International Journal of Surgery Science: A prospective control study evaluating pregnancy outcome in PCOS patients). Often associated with health implementation in later life, “it can affect patients throughout their lifetime from puberty to menopause”. According to The Royal College of Obstetricians and Gynaecologists: “Many women with this condition are obese and have a higher prevalence of impaired glucose tolerance, type 2 diabetes, and sleep apnoea than is observed in the general population. They exhibit an adverse cardiovascular risk profile, characteristic of the cardiometabolic syndrome as suggested by a higher reported incidence of hypertension, dyslipidaemia, visceral obesity, insulin resistance, and hyperinsulinaemia).
“PCOS produces symptoms in approximately 5-10% of women of reproductive age (12-45 years old),” Professor of Pharmacology, Dr Ahmed Kabel, reported in Polycystic Ovarian Syndrome: Insights into Pathogenesis, Diagnosis, Prognosis, Pharmacological and Non-Pharmacological Treatment (Journal of Pharmacological Reports). “It is thought to be one of the leading causes of female subfertility and the most frequent endocrine problem in women of reproductive age.
“The main features of PCOS are anovulation, hyperandrogenism, and insulin resistance,” said Dr Kabel. “Anovulation results in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries. Hyperandrogenism results in acne and hirsutism. Insulin resistance is often associated with obesity, type 2 diabetes, and high cholesterol levels. The symptoms and severity of the syndrome can vary greatly among the affected women. Moreover, it may affect daily physical activities.
Registered dieticians with a special interest in fertility, Carrie Dennett and Judy Simon reported PCOS to be the most common cause of anovulatory infertility with 90-95% of anovulatory patients seeking treatment for infertility having PCOS in The Role of Polycystic Ovary Syndrome in Reproductive and Metabolic Health (Diabetes Spectrum 2015). “Women may learn they have PCOS only after seeking infertility treatment. Most women with PCOS have elevated levels of luteinising hormone and reduced levels of follicle-stimulating hormone (FSH), coupled with elevated levels of androgens and insulin. These imbalances can manifest as oligomenorrhea or amenorrhea. Underproduction of oestrogen and overproduction of androgens by the ovaries can result in a number of additional clinical features, including tiny cysts on the surface of the ovaries,” they said. “Women with PCOS who become pregnant are at higher risk than those without PCOS of developing gestational diabetes mellitus or suffering a first-trimester spontaneous abortion.
“It is well documented that non-pregnant patients with PCOS face more metabolic and reproductive complications with an early or late-term syndrome’s risks,” Razieh Bidhendi Yarandi et al. stated in Diabetology & Metabolic Syndrome 2019. “Normal pregnancy is characterised by the physiologic insulin resistance state, which is at its peak in the third trimester of pregnancy. Human placental lactogen, oestradiol, progesterone, and cortisol regulate the insulin status during pregnancy, which induces the diabetogenic state due to the facilitated diffusion and transfer of glucose to the foetus. Pregnant women suffering from PCOS experience the additive pre-existing state of insulin resistance, which may accompany adverse pregnancy outcomes.”
COMMON PREGNANCY RISKS IN PATIENTS WITH PCOS
Miscarriage: “Approximately 30-50% of pregnancies in women with PCOS end with spontaneous miscarriage during the first trimester, representing a threefold increase compared to healthy women,” reported gynaecologist, Dr Michael Costello (Polycystic ovary syndrome, published in Australian Family Physician Vol. 34, No. 3). “The higher risk of spontaneous abortion observed in patients with PCOS is likely to be confounded by their high prevalence of obesity, an independent risk factor for miscarriage.”
Gestational diabetes: Treatable and, if controlled, gestational diabetes does not cause significant problems for the mother or foetus. The National Institute of Child and Human Development (NIH) explained that in most cases the condition goes away after the baby is born. “Babies whose mothers have gestational diabetes can be very large (resulting in the need for caesarean delivery), have low blood sugar, and have trouble breathing. Women with gestational diabetes, as well as their children, are at higher risk for type 2 diabetes later in life.”
Preeclampsia: Some data suggest that patients with PCOS are at increased risk of developing preeclampsia. According to the NIH, this is a sudden increase in blood pressure after the 20th week of pregnancy and can affect a patient's kidneys, liver, and brain. “If left untreated, preeclampsia can turn into eclampsia. Eclampsia can cause organ damage, seizures, and even death. Currently, the primary treatment for the condition is to deliver the baby, even preterm if necessary. Pregnant patients with preeclampsia may require a caesarean delivery, which can carry additional risks for both mother and baby.
PRECONCEPTION COUNSELLING AND PSYCHOLOGICAL SUPPORT
“As PCOS commonly affects patients of reproductive age, appropriate preconception counselling and advice regarding the impact of lifestyle, obesity, and age on fertility should be offered,” directed gynaecologist, Dr Rose McDonnel and Professor of Reproductive Medicine, Dr Roger Hart (Pregnancy-related outcomes for women with polycystic ovary syndrome published in Women’s Health 2017, Vol. 13). “Emphasis should be focused on the impact that weight has on the clinical presentation and outcomes for women affected by the metabolic, psychological, and reproductive repercussions of PCOS. Women with PCOS have a lower uptake of contraception, which is thought to be due to perceived lower pregnancy rates,” they said. “Women with PCOS should be counselled regarding the appropriate use of contraception to avoid unplanned pregnancy as the pregnancy rates for women with PCOS are similar to those women without PCOS. For those women with PCOS, counselling should be provided that conception may take longer to achieve, hence delaying childbearing may have an accumulative negative impact on the conception when age and BMI are factored in.”
REDUCING IMPACT OF PCOS ON PREGNANCY OUTCOMES
“Lifestyle factors such as diet and exercise should be addressed to optimise BMI, both for a healthier pregnancy and to reduce exacerbation of PCOS,” said Drs McDonnel and Hart. “For those of normal BMI, regular self-monitoring and early action on small increments of weight gain as well as prevention of further weight gain appear to be a feasible approach and more successful than weight loss in women with established obesity. Weight reduction of 5-10% is recommended and has been shown to improve ovulation and subsequent conception and reduce metabolic complications. The behavioural lifestyle change that has demonstrated efficacy is the use of face-to-face-tailored dietary advice, an energy-reduced diet and 150 min of exercise per week,” they continued. “Exercising five times per week for 30 minutes at a time, three of which are recommended to be aerobic in nature has been shown to improve clinical outcomes including insulin resistance even when weight is not lost.”
“When lifestyle treatment does not result in desired outcomes, pharmacotherapy may be added,” said Dennett and Simon. “In premenopausal patients not currently trying to become pregnant, the Endocrine Society recommends hormonal contraceptives as the first-line therapy to manage menstrual abnormalities and reduce hirsutism and acne. Metformin helps to improve insulin sensitivity in both women and adolescents with PCOS, which in turn can decrease circulating androgen levels and normalise the menstrual cycle and ovulation. Clomiphene citrate, an oestrogen receptor antagonist, is the drug of the first choice for induction of ovulation in patients with PCOS.”