What are the common four phenotypes of PCOS? This is important
at least for treatment purpose because till date the treatment of PCOS is
mostly empirical and symptom-based As such scientist and reproductive
biologists have classified PCOS into four broad phenotypes, though there are
many other phenotypes of PCOS. Total 43 phenotypes have been classified by some
International Organizations and also by “Androgen Excess and PCO society”.
However for day to day clinical practice the following classification seems to
be more meaningful.
What are the common four phenotypes of PCOS? This is important
at least for treatment purpose because till date the treatment of PCOS is
mostly empirical and symptom-based As such scientist and reproductive
biologists have classified PCOS into four broad phenotypes, though there are
many other phenotypes of PCOS. Total 43 phenotypes have been classified by some
International Organizations and also by “Androgen Excess and PCO society”.
However for day to day clinical practice the following classification seems to
be more meaningful.
a) Phenotype-I PCOS -> Characteristic will be i)
Oligomenorrhea/sometimes Secondary Amenorrhea; ii) USG will show evidence of
PCOS or PCOM, iii) evidence of hyperandrogenism, iv) Hyperinsulinaemia woman /
Normo-insulinoma woman. In 37.5% of such type-I cases there will be clinical
and laboratory metabolic syndrome. In fact this is the commonest phenotypes of
PCOS as high as 65.6% of PCOS women. If there is documented hyperinsulinaemia
then the doctor should seriously consider the Insulin sensitizer has the first
or initial drug of choice like i) Metformin, ii) Myoinositol & other
isomers, iii) Chr. Pico ate, iv) NAC, v) Vit-D à preferred initial
agent will be drugs to combat IR not the Ovulogen).
b) Phenotype-II: This comprises i) Oligomenorrhea, ii) USG evidence polycystic ovary or PCOM,
iii) usually Normo-androgenic women and
10% will have associated metabolic syndrome (they will need judicious administration
of lipid lowering agents) – If at all hyperandrogenaemia then it’ll be better
to treat them by OCP as an initial drug. If they seek fertility treatment then
it will be prudent to prescribe Pre Tr. with Inj Agonist in previous mid luteal
phase or pre tr. with Progesterone, Inj. Progesterone for consecutive five days
followed by gonadotrophin Inj. and IUI. All these information’s are mentioned
so that many of us don’t unnecessarily carry on with Clomiphene or Letrozole
for months together which will be futile induction. Therefore before we
prescribe CC or Letrozole it will be again good clinical gesture if some
phenotypic classification is made well ahead and a planning a type of induction
is rationally designed. These type-II cases are most likely to be CC resistance
due to high insulin level. However the prevalence of type-II PCOS in India is
about 22.2%.
c) Phenotype-III PCOS: Usually there is i) no Oligomenorrhea (Eumneirrhoic)
or very rarely there can be oligomenorrhoea, ii) USG evidence of PCOS, iii)
Moderate hyperandrogenism, iv) Minimal number of such PCOS women will have
metabolic syndrome. The prevalence of phenotype-III will be only about 1% of
PCOS women. –If history is Oligomenorrheaà Primary agent of Ry will be CC/Anastrazole/
Gonadotrophins in cases who are oligomenorrheic.
d) Phenotype-IV: i) Oligomenorrhea+, b) Ovaries in USG usually
normal pattern with normal echogenicity and volume, iii) hyperandrogenism+, iv)
metabolic syndrome will be associated in 50% of phenotype-IV PCOS. In fact the
prevalence of these phenotypes is 11.2% of all PCOS.
Tips-1: PCOS women seeking fertility restoration – tips for drug
selection seeking women. At first one has to assess TSH, Purl. DHESO4. Now
after estimating all these three hormones we have to supplement or suppress the
hormone milieu. Suppose in there is isolated rise of prolactin hormone,
dopamine agonist (cabergoline or bromocripitine) will suffice. But, who demonstrate
unusual raise of DHEASO4 and/or T4 then my dear members it will be prudent to
find out source of Testosterone by special tests like ACTH stimulation tests,
Serum cortisol etc, 17-OH P etc.
Tips-2: If there is abnormal hair growth then she should ideally
refer to an Endocrinologist and Cosmetic Surgeon if necessary. In these cases
COC alone or in combination with Aldactone will hopefully suffice.
Tips-3: To note that most Obese PCOS, even average weight PCOS
women will mandate Lifestyle modification, Exercise, Dietary Modification,
Vit-D supplementation if serum level is low, Anti-oxidant to prevent onward
vascular damage and only on few occasion some PCOS women will have to take Orlistat
(if obesity but overweight women) and lipid lowering agents particularly if
triglyceride levels are high.
Tips-4: For instance if LH is high and Ovarian Volume is > 12
CC3à then LOD (laparoscopic
Drilling of ovaries) may be given priority to maximize the efficacy of Tr of
ovulation induction..
By contras if there is predominate hyperinsulinaemia in a
clinically suspected PCOS then one should can allow fair trial with insulin sensitizers
for couple of months without resorting Clomiphene /Anastrazole or gonadotrophin
inj-not to speak of ART.
The beauty of insulin sensitizers is those such drugs but not
all insulin sensitizers in addition to controlling plasma glucose but also reduce
circulating serum androgens. We should
keep in mind that Letrozole reduces or should I say normalizes the ovarian bio synthesis
of androgens—in the cortical tissue of ovaries).
