Common four phenotypes of polycystic ovaries -A metabolic diseases primarily sometimes associted with subfertility/

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) Type-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-insulinmic 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. Piconate, iv) NAC) Vit-D à preferred initial agent will be drugs to combat IR not the Ovulogens).

b) hyperandrogenaemia /Normo-androgenic women –If hyperandrogenaemic: -- TR by OCP / Pre Tr. With Inj Agonist in mid luteal phase/ Progesterone

c) Eumneorrhoic or oligomenorrhoea woman –If history is oligomenorrheicà  Primary agent of Ry will be CC/Anastrazole/ Gonadotrophins in cases who are oligomenorrheic.

d) Fertility restoration seeking women --who demonstrate unusual raise value of DHEASO4/ T4:- to find out source of Testosterone by special tests-ACTH stimulation tests, Serum cortisol etc, 17-OH P etc.

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. Etc.

Therefore my proposition to Forum members is to diagnose or pinpoint the exact pathology the candidate is suffering from instead of putting her in a broad category of PCOS which encompasses any many many metabolic/ hormonal abnormalities, for example a woman may be designated as a) normo insulinaemic, b) hyperandrogenic, c) oligomenorrheic d) normal weight e) anovulatory woman instead if labeling her PCOS. What is the view f Forum members about such stratifying in initial diag work up? The limitations are initial high cost of Lab tests and difficult to interpret the Lab values of insulin / Testosterone. Unfortunately the Lb methodology of these two hormonal parameters (Insulin/ T4) has not been standardized.

This reminds me our ward Round in Medicine indoor –where one our Visiting was always unhappy to hear the term Mitral stenosis. Instated he insisted that we should write the diagnosis in the following format e.g. 1) Rheumatic 2) mitral stenosis with 3)  normal heart rate( means no fibrillation)  with 4)  no failure and 5) no clinical evidence of Pulm oedema who had no previous surgery for stenosis. He insisted that will help the clinician to formulate TR Plan. I, follow his path of thinking. I hope we can apply his philosophy in posed PCOS cases more appropriately.

 `Etc d) ovulatory /anovulatory. Admittedly , Lab diagnosis of hyperinsulimeania and or hyperandrogenaemias difficult but honestly speaking have a feeling that  all women seeking fertility Tr who are primarily labeled as PCOS/ PCOM should have identification of the type and degree of metabolic milieu or hormonal milieu so as to maximize the choice of or selection of initial protocol.

For instance if LH is high and Ovarian Volume is > 12 CC³à then LOD may be given priority to maximize the efficacy of Tr.

By contras if there is predominate hyperinsuineamia in a clinically suspected PCOS we can allow fair trial of in, sensitizers for couple of months without resorting to CC/Anastrozole or gonadotrophin inj-not to speck of ART.

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