Polycystic ovarian syndrome, or PCOS, is a condition that affects about 10 million women in the world. It is the most common endocrinopathy among women of reproductive age.
PCOS is important for underwriters to recognize because it is so pervasive. The syndrome can have a wide range of long lasting physical, mental, and emotional impacts, so understanding the symptoms and long-term effects is crucial for underwriters to make an informed assessment.
What is PCOS?
PCOS was initially described in 1935 by American gynecologists Irving F Stein, Sr. and Michael L. Leventhal (which gave it its other name, Stein-Leventhal Syndrome). The doctors correlated the presence of ovarian cysts with anovulation. These factors were used as diagnostic criteria for many years, until it was understood that elevated androgen levels (not ovarian cysts), as well as anovulation, were the appropriate criteria for the syndrome.
PCOS is the leading cause of female infertility and is responsible for a number of symptoms that can impact the body physically and emotionally. Although the exact cause of PCOS is not known, researchers consider it a hormonal problem. Genetics and environmental factors are also believed to contribute to the development of PCOS.
What does PCOS affect?
PCOS is a hormonal imbalance. Hormones involved in PCOS include:
- Androgens or male hormones: Androgens are produced in the ovaries, adrenal glands, and fat cells. They are believed to regulate the function of many organs including the reproductive tract, aid in maintaining an overall sense of well-being, as well as play a key role in the prevention of bone loss.
- Insulin: This hormone allows the body to absorb glucose (blood sugar) into the cells for energy. This can potentially lead to increased glucose levels which in turn makes the body produce more insulin.
- Insulin and Androgen Links: Elevated levels of insulin can cause the body to create more androgens. If left untreated, elevated androgen levels are associated with insulin resistance and diabetes as well as high cholesterol, elevated blood pressure, and heart disease.
- Progesterone: Progesterone is produced in the ovaries following ovulation. It triggers the endometrium to thicken in order to accept a fertilized egg.
Symptoms of PCOS
Symptoms of PCOS can begin shortly after puberty but they can also develop in later teen years into adulthood. The most common symptoms of PCOS are, but are not limited to:
- Irregular menstruation or amenorrhea (the absence of menstruation)
- Menorrhagia (heavy menstrual bleeding)
- Weight gain
- Hirsutism (excessive body hair in irregular areas)
- Mood changes
- Pelvic pain
- Acanthosis nigricans (darkening of the skin due to insulin resistance)
There is no single test to diagnose PCOS. A physical exam, blood tests, and a pelvic ultrasound are often useful in diagnosing PCOS. Primary physicians also refer patients to endocrinologists (hormone specialists) to get a better picture of a patient’s condition.
The Rotterdam criteria is the most widely accepted scale for diagnosis. Two of the three criteria need to be present in order to confirm diagnosis.
- Oligomenorrhea (infrequent menstruation) or anovulation (no ovulation)
- Hyperandrogenism: Clinical (hirsutism or less commonly male patter alopecia) or Biochemical (raised FAI or free testosterone)
- Polycystic ovaries on ultrasound
There is no cure for PCOS. Treatment is aimed at managing the symptoms of PCOS and lowering the risk of long-term complications such as diabetes and heart disease. Common treatments are:
- Intermittent progestogens or oral contraceptives
- Infertility treatments in women who desire pregnancy
- Weight management, diet, and lifestyle changes
- Metformin and/or Pioglitazone (medications to control blood sugar)
- Surgery (such as ovarian drilling)
- Smoking cessation
There are also a range of complications and challenges associated with PCOS. Some include:
- Non-alcoholic steatohepatitis (NASH)
- Metabolic Syndrome
- Type 2 diabetes or pre-diabetes
- Sleep apnea
- Abnormal uterine bleeding
- Endometrial cancer
- Abnormal cholesterol and triglyceride levels
- Heart disease and stroke
What does this mean for an underwriter?
The severity and impact vary greatly between individuals, so an extensive and specific investigation should be undertaken to assess risk. When an underwriter is assessing a person who has been diagnosed with PCOS, the key factors that need to be taken into consideration are:
- Age of Onset: Women of child-bearing age can be negatively impacted due to difficulties conceiving with a diagnosis of PCOS.
- Investigations: It is important to understand if the patient has been fully investigated. A thorough diagnosis can rule out other more serious causes of hormonal imbalances and hirsutism (i.e. adrenal tumor, Cushing’s disease, etc.).
- Treatment and Management: Look out for build, abnormalities in labs, smoking, and medications. Make sure there are no underlying complications like impaired glucose tolerance/diabetes, metabolic syndrome, or psychiatric disorders.
As with underwriting any medical condition, a full picture is always required. Treatment and management of PCOS, as well as any complication or co-morbidities, should be taken into consideration. Regular follow-up, yearly blood testing to screen for diabetes, heart disease, and weight management are all positive ways to stay on top of PCOS.