CUTANEOUS MANIFESTATIONS OF POLYCYSTIC OVARIAN DISEASE
Journal Title: Journal of Evolution of Medical and Dental Sciences - Year 2018, Vol 7, Issue 26
Abstract
BACKGROUND Polycystic ovarian disease (PCOD) is an ill-defined heterogeneous condition with a complex pathophysiology and is one of the commonest endocrine/metabolic disorders, affecting 6 - 10% of women in their reproductive age. Polycystic ovarian disease is the most common endocrine cause of hirsutism, acne and androgenic alopecia. MATERIALS AND METHODS Informed oral consent was obtained from all subjects after explanation of the nature and purpose of the study. A special case proforma was prepared to record the demographic data, complaints, history, clinical examination and results of investigations. A detailed history regarding menstrual irregularities, reproductive function, hirsutism, acne, androgenic alopecia, acanthosis nigricans, acrochordons, seborrhoea and other skin changes. Patients were also enquired about use of cosmetics, hoarseness of voice, headache, milky discharge from breast, mass over anterior neck, weight gain, diet, exercise, use of any medications or other forms of treatment, any stress/illness, history of diabetes mellitus, hypertension and coronary artery disease. Family history of polycystic ovarian disease, diabetes mellitus, hypertension, coronary artery disease, metabolic syndrome and cancers was also taken. Menstrual and obstetric history and any medical or surgical illness was recorded. Other causes of acne, hirsutism and alopecia were excluded by appropriate history and examination. All subjects underwent a detailed clinical examination with special reference to the following parameters: Hirsutism scoring was done using modified Ferriman-Gallwey (mFG score) and it was classified as mild (mFG score 9 - 16), moderate (mFG score 17 - 25) and severe (mFG score 26 - 36). Acne was graded as done by Indian authors using a simple grading system, which classifies acne vulgaris into four grades. Androgenic alopecia was looked for and graded as per Sinclair scale. It was also further classified as Ludwig type, Norwood Hamilton type and Olsen type. Acanthosis nigricans was looked for at multiple sites as neck, axilla, submammary area, intermammary areas, groins, elbows, knees, knuckles, dorsum of feet, cubital and popliteal fossa, periumbilical area, face-lips and eyelids. Other causes of the above symptoms and signs were excluded. Entire skin, hair, nails and mucosae were examined for any abnormality. Genitals were checked for any clitoromegaly or vulvar acanthosis. Galactorrhoea and thyroid fullness was looked for. RESULTS The peak incidence of polycystic ovarian disease was seen in patients with age group of 21 - 25 years followed by 26 - 30 years. Among the dermatologic and gynaecological complaints, hirsutism, i.e. a cutaneous manifestation was the most common, seen in upto 84% of the women and showed varying severity. The mean Ferriman-Gallwey score was 16.8 +/- 5.39. Hirsutism was most commonly found over the upper lip and lower abdomen followed by thighs, upper abdomen and lower back, chest and upper back, chin and upper arms. Acne was seen in 70% of the patients. Grade II severity acne was the most common presentation followed by Grades III, I and IV respectively. The most common site was face followed by neck, back, upper arms and front of chest. Androgenic alopecia was seen in 32% of the women. The most common clinical type was Ludwig followed by Olsen and Norwood Hamilton type. As per Sinclair scale, grade II severity androgenic alopecia was most common. Acanthosis nigricans was seen in 56% of the patients. The most common site was nape of the neck followed by axilla, groin and submammary areas. The SAHA syndrome, i.e. the combination of seborrhoea, acne, hirsutism and androgenic alopecia was seen in 3 patients. Acrochordons were seen in 32% and seborrhoea was found in 30%. Common gynaecological complaints were oligomenorrhea [62%] and amenorrhea [12%]. Married women commonly presented with infertility [68%]. Significant proportions of our patients had increased BMI and were overweight or obese. Many of them also had central obesity with increased waist circumference and waist-hip ratio. A family history of polycystic ovarian disease was observed in many of the women, either in the mother or siblings, indicating a genetic predisposition to polycystic ovarian disease. Though most of the patients did not have diabetes mellitus, hypertension or coronary artery disease at the time of presentation, many of them had a family history of the same, indicating a predisposition to metabolic syndrome. Among the biochemical assays, though total testosterone was raised in only 6%, free testosterone was raised in 32%, indicating decreased SHBG levels. LH:FSH ratio was raised in 18% and serum prolactin was high in 20% of the women. Ultrasonography detected polycystic ovaries in 96% of the polycystic ovarian disease patients. CONCLUSION Polycystic ovarian disease is the most common chronic debilitating endocrinopathy of women in the reproductive age group with long-term health consequences. Dermatological problems like hirsutism, acne, androgenic alopecia, acanthosis nigricans and seborrhoea may serve as markers for identifying the polycystic ovarian disease syndrome, which may otherwise be resistant to routine treatments. Further studies are required to assess the grading of severity of these symptoms in PCOS patients, which may help to establish the severity of the syndrome. Also, these may serve as markers for patients at risk of developing metabolic syndrome. Early recognition of this disorder gives a chance to reverse the symptoms and signs associated with the disease, while correcting the metabolic abnormalities that may pose a significant health risk for untreated individuals and improving the physical, social and mental well-being of the patient. Early recognition also provides a chance for lifestyle modification [i.e. a comprehensive program of diet, exercise and behavioural therapy] that improves insulin resistance, dermatological complaints, menstrual irregularities, fertility and also decreases long-term health risks. However, more research in the genetic and environmental factors is needed to underscore preventive strategies in future in families with polycystic ovarian disease.
Authors and Affiliations
Thakur Rajeev Singh, Sathaiah Sudhamalla
Keywords
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- EP ID EP466496
- DOI 10.14260/jemds/2018/685
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