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Polycystic ovary syndrome

Dr. Fayiz F. Elshamy

Assist. Prof of Physical Therapy for Women's
Normal Ovulation process
Hypothalamus produces gonadotropin-releasing
hormone (GnRH) which signals to the pituitary to
produce LH and FSH.
The normal pulsatile release of GnRh signals some of
the follicles in the ovary to begin maturing and for the
ovaries to release estrogen and progesterone. This
estrogen/progesterone signal is recognized by the
pituitary gland. As the follicles begin maturing they
release and increase the hormone estrogen over time.
The rising estrogen level signals the pituitary gland to
restrict the release of FSH. This communication allows
for ovulation to occur. 2
Polycystic ovary syndrome (PCOS) is the most common
endocrine disorder in female. Its prevalence among
infertile women is 15% – 20%. It is recognized that
affected 5-10% of the women across the world.

PCOS features include:-

Menstrual cycle disturbance,
Hyperandrogenism and

Causes of PCOS

The cause of PCOS is unknown.

It is believed that 25% of women with PCOS is
*An inherited(Genetic) disorder,
*Endocrine malfunction and
*Environmental factors.

Abnormalities in polycystic ovary syndrome


 Genetics
 Insulin Resistance
 Obesity
 Low-grade Inflammation
 Increased sympathetic activity

In PCOS women
The hypothalamus releasing GnRH in a higher than
normal frequency. This allows for increased LH and
decreased FSH, which in turn leads to excessive
production of the androgens. This causes the follicle to
only mature some, but not enough to achieve full
maturity in order to be released for ovulation. This also
allows for continued increase of estrogen. The higher
levels of androgens and estrogen create a chronic state
of low to very low progesterone and anovulatory cycles.

Signs and Symptoms of PCOS

The symptoms of PCOS can vary from woman to woman

 Irregular menstrual cycles

 Anovulatory cycles
 Excessive or heavy menstrual bleeding
 Recurrent Miscarriage
 Alopecia
 Hirsutism
 Acne
 Acanthosis nigricans – a darkening of the skin in the armpits, back of the
 Mood disorders
 Obesity
Obesity Alopecia

Acne Hirsutism

Symptoms of PCOS
Complications of PCOS

 Hypertension
 High cholesterol
 Anxiety and depression
 Sleep apnea
 Cardiovascular disease
 Diabetes
 Endometrial and breast cancer

Diagnosis of PCOS
Review medical history and symptoms of patient and perform tests to
rule out other possible conditions as
Congenital adrenal hyperplasia,
Androgen-secreting tumors, or
Cushing’s syndrome.
Pituitary and Ovarian Hormone serum levels:
 Luteinizing Hormone (LH)

 Follicle Stimulating Hormone (FSH)

 Estradiol

 Progesterone

 Prolactin

Circulating Androgens:
 *Free testosterone
 *Free androgen index (FAI): 17-hydroxyprogesterone
 *Sex hormone binding globulin (SHBG): 24 hr. urinary free
 *Dehydroepiandrosterone sulfate (DHEA-S)
Endometrial Biopsy
Glucose Tolerance Test
Thyroid Panel
Blood Lipid Profile

Sonographic features of PCOS include the presence of 12
or more follicles in each ovary measuring 2–9 mm in
diameter and/or increased ovarian volume (>10 mL).

A pelvic laparoscopy
It is a surgical procedure in which a small incision in
abdomen will be made and a tiny camera will be
inserted to check for growths on the ovaries. If growths
are present, a small tissue sample (biopsy) will be taken
for further examination.

Diagnostic criteria of PCOS

PCOS treatment
Because there is no cure for PCOS, it needs to be
managed to prevent problems. Treatment goals are
based on symptoms.

*Lifestyle modification and nutrition guidelines.

*Contraceptive pills.
*Diabetes medications.
*Fertility medications.
*Surgical treatment.

Lifestyle modification and nutrition
Many women with PCOS are overweight or obese,
which can cause health problems, manage PCOS
by eating healthy and exercising to keep weight at a
healthy level.

Balance daily protein intake with an equal amount of carbohydrates

Eat foods low on the glycemic index. As Broccoli, Beans ,Grapefruit and
Eat a diet high in fiber
Eat essential fatty acids daily.
Eat 5 - meals / day
Exercise for 30 minutes, 5 days / week
Eat Organic
Quit Coffee. Women who drink 4-5 cups of coffee a day produce 70% more
estrogen in the follicular phase of the menstrual cycle .
Contraceptive pills.
For women who don't want to get pregnant, contraceptive
pills can:
*Control menstrual cycles
*Reduce male hormone levels
*Help to clear acne

Diabetes medications.
Metformin controls blood glucose, lowers testosterone
production, slow the growth of abnormal hair and, may
ovulation to return.
Metformin decreases body mass and improved

Fertility medications.
Antiesrogens & Gonadotropins.
It has many side effects as hot flushes, abdominal distention,
breast discomfort, nausea, vomiting, visual symptoms,
headache, fetal malformation and twins, triplets.

Surgical treatment.
When a PCOS woman does not respond to fertility medicines.
It reduces number of theca cells producing testosterone .
The various surgical methods for doing this include:-

*Wedge resection
*Ovarian drilling
*Ovarian diathermy

Weight loss

It is a first line of therapeutic option in all women with

obesity and PCOS.
 A) Diet
 B) Mild to moderate aerobic exercise.
 C) Low calorie diet & Exercise
 D) Low calorie diet & antidiabetic drug
 E) Low caloric diet & electrolipolysis

A) Diet :
 Moderate energy restriction (1000-1200Kcal/day)
* BMI of 27 or more.
*BMI of 25 or more with co-morbid conditions or when Waist/Hip ratio > 88 in female
 Severe energy restriction(400-800Kcal/day)
*BMI of 30 or more.
*BMI of 27 or more with co-morbid condition

B) Mild to moderate aerobic exercise at 50-70% of Vo 2 max for > 45

minutes daily for 3 -6 months
 Reduce fasting leptin by 17.5%, fasting insulin, LH pulse frequency and
androgen production.
 Avoid vigorous exercise that induced changes of the anterior pituitary & the
hypothalamus resulting in female reproductive dysfunction

C) Low calorie diet & Exercise
For 6-months to counteract the negative metabolic adaptations that occur
during caloric restriction.

D) Low calorie diet & anti-diabetic drug

To reduce insulin resistance as well as hyperinsulinemia and correct the LH

E) Low caloric diet & electro-lipolysis
  Low caloric diet(1200 kcal/day) and electro-lipolysis for 3-months is an
effective methods for reducing weight, LH and LH/FSH ratio and resuming
normal ovulatory cycle.

Parameters of electrolipolysis
 Contraction time: 4-seconds followed by 4-seconds of relaxation time
 Frequency: 100 pulses/minutes.
 Pulse width: 400 microseconds.
 Placement of electrodes: on the abdominal and gluteal region (medius & maximus).
 Duration: 30 minutes on the abdominal region and other 15 minutes on each gluteal

The physiological effect of electrolipolysis

Effect on skeletal muscle activities:

 Muscle contractions utilize glycogen, fat and other nutrients stored in the
 Also, it stimulates nerve ending leads to release of catecholamine leading to
activation of lipases, that hydrolysis fat into glycerol and fatty acid.

Effect on adipose tissues :

 In human, adipose fat cells are stored as triglycerides. A molecule of
triglyceride comprises one molecule of glycerol and three of fatty acid;
lipolysis breaks the bond of triglyceride molecules creating four simple
molecules. These easily pass through the cell wall and into the interstitial
fluid as the fat cells reduce in size and the volume to be further transported
by the lymph vessels.
 Lymphatic Drainage greatly speeds up the process.
Acupuncture in polycystic ovary syndrome
 Acupuncture may be used as an alternative or a
complement to pharmacological induction of
ovulation in women with PCOS who have minor
metabolic disturbance.
 Intramuscular needle insertion cause a particular
pattern of afferent activity in peripheral nerves.
Depending on the intensity, stimulation of the
acupuncture needles(Manual or Electrical) activate
muscle afferents to the spinal cord and the central
nervous system.
 Acupuncture points selected according to the
innervations of the ovaries (Th12 –L 2, S2 –S4). (As
 Stainless steel, disposable one-time sterile needles
(size 0.32 mm in diameter and the length of 3 or 5
cm) were inserted intramuscularly to a depth of 1.5–
3.5 cm. 26
For example
 Needles in abdominal muscle and in the leg were attached
to an electrical stimulator and stimulated electrically with
low-frequency EA of 2 Hz with square-wave burst pulses (a
burst length of 0.1 s and a burst frequency of 80 Hz) with
alternating polarity.

 The intensity of the electrical stimulation was adjusted to

produce local muscle contractions, as strong as possible,
without pain and discomfort. The needles stimulated
manually by hand with rotation of the needle through an arc
of at least 180 degrees to evoke needle sensation every 10
min. Each treatment lasted 30 min, was given two per week
during 2 weeks, one per week during 6 weeks, and once
every second week for 8 weeks, in a total of 14 treatments
during 16 wk.

Effect on metabolic pattern

Low-frequency EA (4–5 weeks)

with repetitive muscle
contractions activate
physiological processes similar
to those resulting from physical
exercise which induces weight
loss and increases insulin
sensitivity, reducing blood
glucose and lipid levels .

Effects on ovulation

 Acupuncture decrease cortisol concentrations and modulate

central and peripheral B-endorphin secretion, thereby
influencing the release of hypothalamic GnRH and pituitary
secretion which regulate the insulin and ⁄ or LH, FSH secretion
and normal ovulatory cycle .
 Acupuncture modulates spinal reflexes. Low-frequency EA
increased ovarian blood flow. The response was mediated via
ovarian sympathetic nerves as a reflex response and
controlled by supraspinal pathways.

Effect on the sympathetic nervous system
Low-frequency EA decrease ovarian sympathetic activity.

Effect on mental health

Acupuncture might be helpful in the treatment of depression

Laser Acupoints on Women With
Polycystic Ovarian Syndrome

Laser acupuncture for 3 months can be suggested

as an effective management for PCOS women.
During which time they undertook,
2-sessions/week during first 2weeks, one
session/week through 4 weeks, and one session
every seconds week for 6 weeks, in a total of 11
sessions through 12 weeks. El-Shamy FF et al .,2018

Laser Acupoints

Ren 4(Unilateral). On the midline, 3 cun lower to the umbilicus.

Ren 5(Unilateral). On the midline, 2 cun lower to the umbilicus.
St 29(Bilateral). 4 cun under the umbilicus, 2 cun sideways to the
Sp 6(Bilateral). 3 cun higher than the tip of the medial malleolus on
theposterior margin of the tibia.

Laser Parameters

An infrared laser with 830 nm wavelength, 10

mW power output and 0.5 J energy was applied
60 seconds for each acupoint. The head of the
machine was used perpendicularly, with direct
contact to each point.

Its physiological effects

1- Reduces the level of cytokines discharged from white blood cells

as inflammatory response

2-The enhancement of ions transportation over the cell membrane,

that occur in instances of IR, and contribute to lessening the insulin

3-Diminishes central B-endorphin, causing a decreased sympathetic


4-Iimprove uterine blood flow and enhancement of infertility .

5- Skin light contact stimulate mechanoreceptors which regulate

activity in the central nervous system.
Herbal treatment

It corrects the hypothalamic pituitary ovarian(HPO) axis and the resultant

hormonal imbalance.
Licorice root helps the body to maintain proper hormone production
and release. Licorice also supports healthy insulin levels and liver
health which is important for women with PCOS.
Cinnamon reduce insulin resistance in women with PCOS by slowing
the movement of food from the stomach to the small intestine.