Content uploaded by Chukwuemeka Iyoke
Author content
All content in this area was uploaded by Chukwuemeka Iyoke
Content may be subject to copyright.
Prevalence, Presentation and Management of Polycystic Ovary Syndrome
in Enugu, South East Nigeria
Corresponding author: Dr George O Ugwu, Department of obstetrics and gynaecology, University of Nigerian Teaching Hospital Ituku Ozalla, Enugu.
E-mail: ugwugeo@yahoo.com
UGWU GO, IYOKE CA, ONAH HE, MBA SG
Department of obstetrics and gynaecology, University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu.
ABSTRACT
BACKGROUND: Polycystic ovary syndrome is the
most common gynaecological endocrine disorder in
women of reproductive age yet, its prevalence and
management has not been documented in our area.
OB JECT I VE: To det ermin e the preva lence ,
presentation and management of polycystic ovary
syndrome among women in Enugu, south east Nigerian.
METHOD: A prospective descriptive study of women
with polycystic ovaries seen in two major Infertility
Clinics in Enugu, South East Nigeria over a 2 year
period.
RESULT: A total of 342 women presented with
infertility in the centres within the two year period,out of
whom 62 had PCOS. PCOS occurred in 18.1% of
women in the infertility clinics of the two institutions.
The common modes of presentation were: inability to
conceive (infertility) in 52(83.9%), oligomenorrhoea in
45(72.6%), obesity in 32 (51.6%), LH/FSH ratio > 2 in
28(45.2%), hyperprolactinaemia in 26(41.9%) and
hirsuitism in 19(30.6%) women. Ovulation induction
was carried out in 42 of the 50 women with anovulatory
infertility only. For those 42 women, the mean number of
induced cycles was 2.6 = 1.7(range: 1-6) with 33
(78.6%) of the women being able to do only 3 induced
cycles or less. The ovulation induction agents used were
clomip h e n e cit r a t e and human me n op au sa l
gonadotrophin either singly or in combination with
tamoxifen or bromocryptine. Adjunctive treatments
offered consisted of weight reduction in 20(40.0%)
women, metformin in 11(22.0%) women and
d e x a m e t h a s o n e i n 1 0 ( 2 0 . 0 % ) w o m e n .
CONCLUSION: PCOS is fairly common occurring in
approximately one in six infertile Nigerian women.
Infertility, oligomenorrhoea, obesity, LH/FSH ratio > 2,
hyperprolactinaemia and hirsutism are the commonest
presenting features. On individualized management,
about two-fifths of them conceive either spontaneously
or following ovulation induction, despite poor
compliance to recommended drug regimen.
Date Accepted for Publication: 30th August, 2013
NigerJMed 2013: 313-316
Copyright Ó 2013. Nigerian Journal of Medicine
INTRODUCTION
The Polycystic Ovarian Syndrome (PCOS), consisting
of oligo-amenorrhoea, obesity, infertility and hirsuitism,
1
was first described by Stein and Leventhal . Since then
the disorder has remained an enigma although a lot has
been learnt about its pathophysiology. For example, it
has become clear that it represents a spectrum of
dis o r de rs wi th so me w o men show i n g f e w
sig ns/sym p toms and oth e rs showin g al l th e
2, 3
signs/symptoms . It is also now known that the
disorder is associated with long term health sequelae for
those affected including type 2 diabetes mellitus,
increased risk of endometrial cancer and cardiovascular
2
disease amongst others .
The exact underlying defect in PCOS is unknown, a
genetic component is likely as PCOS tend to occur
among family members. The leading risk factors
include hyperinsulinaemia secondary to insulin
resistance, obesity and family history of PCOS among
3.
first degree relatives PCOS may present with various
features including oligomenorrhea, anovulatory
infertility, obesity, hirsutism, polycystic ovaries with or
without ovarian enlargement.
For several years now, we have noted an increasing
number of women presenting with PCOS in our practice.
To the best of the author's knowledge, PCOS has not
been characterized in terms of prevalence,presentations
and management amongst Nigerian women. This study
had the following objective: to document the prevalence,
presentation and management of PCOS patients seen in
Enugu, South Eastern Nigeria.
METHODS
This was a prospective descriptive study of women who
st th
presented with PCOS from 1 January 2008 to 30
December, 2010 at the University of Nigeria Teaching
Hospital, and Mbanefo Specialist Hospital both in
Enugu, South Eastern Nigeria. The two institutions were
the leading fertility centres in the region and had the
needed facilities to investigate and treat PCOS.
The definition of PCOS used for this study was the one
adopted at the joint consensus meeting of the American
Society for Reproductive Medicine and the European
Society of Human Reproduction and Embryology
(ASRM/ESHRE), namely the presence of two out of the
following three criteria: 1. Oligo- and/or anovulation 2.
Hyperandrogenism (clinical and/or biochemical) and 3.
Polycystic ovaries with the exclusion of other
4
aetiologies . A polycystic ovary was defined in the study
as an ovary with 12 or more follicles measuring 2-9mm
3 5
in diameter and/or increased ovarian volume (>10cm ) .
Original Articles
313
Nigerian Journal of Medicine, Vol. 22 No. 4, October - December, 2013, ISSN 1115 - 2613
History was taken from, and physical examination
performed on, all women who presented with infertility
and menstrual disorders to the health institutions during
the study period. Subsequently, they underwent
r e l e v a n t i n v e s t i g a t i o n s i n c l u d i n g
transabd o m i n a l / t r a n s v a ginal ul t r a s o n o g r a phy,
hormonal assays, saline infusion hysterography or
hys t erosal p ingogra p hy and laparos c o py with
hydrotubation as considered appropriate. Those with
PCOS were identified using the definition above. Details
of the presenting features, results of investigations and
individualized management plan were keyed into a
proforma by the investigators. For the women who
presented with infertility, their husbands also underwent
semen analysis. Patients were followed up and the above
info rmation updated until patients conclusive
management (pregnancy and or resolution of symptoms)
or loss to follow up.
Regarding management, the patients with PCOS were
categorized into three: Those with anovulatory
infertility only; those with combined factor infertility
and those with menstrual disorders only (i.e. no
immediate need for pregnancy). The management of
each woman was individualized.
Those with anovulatory infertility only underwent
ovulation induction. Ovulation induction was carried
out using clomiphene, tamoxifen, human menopausal
gonadotrophins, human chorionic gonadotrophins,
bromocryptine either singly or in combination. The
doses of the drugs were individualized depending on the
responses seen on scan. Follicular tracking was done
using serial transvaginal ultrasonography . Adjunctive
treatment was also given as indicated including:
metformin or weight reduction . Some cases showing a
poor response to ovulation induction were counseled for
ovarian drilling.
The second group with combined factor infertility were
referred for ICSI/IVF because with a combination of
tubal and male factor infertility a form of assisted
reproduction was necessary. The third group with only
menstrual disorders were given combined oral
contraceptives or cyclical progestogens with or without
a recommendation of weight reduction.
Data analysis was by descriptive statistics using the
statistical software for the social sciences ( SPSS )
version 17 for windows .
RESULTS
Sixty-two women were diagnosed as having PCOS in
the two health institutions within the study period. Fifty
women presented with anovulatory infertility , 2 had
combined factor infertility, while 10 of the women at the
infertility clinics presented with menstrual disorders. A
total of 342 women presented with infertility in the
centers within the two-year period, the prevalence of
PCOS among the infertile population was 18.1%.
The mean age of the patients was 30.0 + 5.2 (range: 17-
41 years) and mean parity 1.0 + 1.0 (range: 0-5). Fifty-
three (85.5%) of the respondents were married while 9
(14.5%) were single.
The clinical presentation for the patients is summarized
in Table 1. The common modes of presentation were:
inability to conceive (infertility) in 52 (83.9%),
prolonged cycle length (oligomenorrhoea) in 45
(72.6%), obesity in 32 (51.6%), LH/FSH ratio > 2 in
29(46.8%), hyperprolactinaemia in 26 (41.9%) and male
pattern hair growth( hirsuitism )in 19 (30.6%) women.
Based on mode of management, patients were
categorized into three:
1. Those with anovulatory infertility only 50
women;
2. Those with anovulatory, tubal and/or male
factor infertility 2 women,
3. Those not desirous of pregnancy 10 women.
For the 52 women who presented with infertility, the
mean duration of infertility was 4.2 + 4.6 (range: 1-24
years). Ovulation induction was carried out in 42 of the
50 women with anovulatory infertility only. For those
42 women, the mean number of induced cycles was 2.6 +
1.7 (range: 1-6) with 33 (78.6%) of the women being
able to do only 3 cycles or less (Table 2).
Parameter
Inability to conceive
Oligomenorrhoea
Obesity (Absolute weight > 90 kg or
2
BMI > 25 kg/m ) LH/FSH ratio > 2
Hyperprolactinaemia
Hirsuitism
Acne
Amenorrhoea
Incidental finding with regular menses
Metrorrhagia
Elevated testosterone
Diabetes mellitus
No
52
45
32
29
26
19
16
8
7
4
2
1
Percent
83.9
72.6
51.6
46.8
41.9
30.6
25.8
12.9
11.3
6.5
3.2
1.6
Table 1. Clinical features of Polycystic ovarian syndrome
among infertile women in Enugu (N = 62)
Table 2 Completed ovulation induction cycles in 42
Nigerian women with PCOS
Completed
cycle(s)
1
2
3
4
5
6
Total
No
12
13
8
2
2
5
42
Percent
28.6
31.0
19.0
4.8
4.8
11.9
100.0
Cumulative
Percent
28.6
59.6
78.6
83.3
88.1
100.0
314
Nigerian Journal of Medicine, Vol. 22 No. 4, October - December, 2013, ISSN 1115 - 2613
The ovulation induction agents used were clomiphene
citrate, and human menopausal gonadotrophin either
singly or in combination with tamoxifen, or
bromocryptine (Table 3).
Adjunctive treatments offered consisted of weight
reduction in 20 (40.0%) out of the 50 women with
anovulatory only infertility, metformin in 11 (22.0%)
women and dexamethasone in 10 (20.0%) women.
There was poor compliance with the adjunctive
treatments as less than 3 women complied and
completed any of them as recommended. Three of 8
women who were offered ovarian drilling for poor
ovarian response to ovulation induction accepted and
had the procedure carried out. One of the three women
who underwent ovarian drilling subsequently became
pregnant and had a live delivery. Another had her
menses regularized but did not achieve pregnancy while
the third neither had achieved pregnancy nor regular
menses. For all patients, the mean duration of follow-up
was 12.6 + 16.1 (range: 3-72) months.
Overall, 19 (38.0%) out of the 50 infertile women
became pregnant. Ten (52.6%) of these conceptions
occurred spontaneously while another 9 (47.4%)
followed ovulation induction. Out of the ten cases who
conceived spontaneously, 6 had completed 6 cycles of
ovulation induction, which they discontinued for a
minimum of 3 months before they became pregnant. Of
the 19 pregnancies, 2 had miscarriage while the rest were
carried to term. Four women (8.0%) did not exhibit any
follicular development even with HMG. Ovarian
hyperstimulation was seen in two women (4.7%) of
those who had ovulation induction.
Twelve women (including the two with combined factor
infertility were referred for in-vitro fertilization and
embryo transfer or ICSI. At the time of writing, none of
them had been able to access IVF-ET or ICSI because of
financial constraints. Of the two medical options of
treatment offered to those who were not desirous of
pregnancy combined oral contraceptives and cyclical
progestogens all chose cyclical progestogens. None of
them complied well with the treatment for more than 3
months. There was also poor compliance in 5 of them
who were obese and were counseled on weight
reduction.
DISCUSSION
The prevalence of PCOS (18.1%) recorded in this study
is lower than the 20-43.5% recorded in Caucasian
6, 7
populations . The differing prevalence rates most
probably reflect differences in the prevalence rates of the
genetic and environmental determinants of PCOS in the
various populations or differences in study populations.
The prevalence rate recorded in this study is based on a
cl inic popul atio n and the refore may not be
representative of the general Nigerian women
population. A population-based study is highly
recommended but may be difficult to carry out because
of logistic reasons.
The clinical features of PCOS in the study subjects do
not differ from the ones recorded in other published
3,8
series . Thus not surprisingly, anovulatory infertility,
oligomenorrhoea and obesity were the major presenting
features. The lesson here is that clinicians in Nigeria
ought to rule out or confirm PCOS in women presenting
with such features since such women are at high risk of
developing ovarian hyperstimulation syndrome and
other long term health problems such as diabetes and
9,10
cardiovascular disease as documented in other studies .
To take care of the differing needs of the patients, their
management was individualized. In the first instance
they were categorized according to whether they had
only anovulatory infertility or combined factor
infertility or were not worried about getting pregnant.
For those with anovulatory infertility only, ovulation
induction was carried with various agents. Adjunctive
treatment is in the form of weight reduction, metformin
and dexamethazone. This notwithstanding, a high
default rate was observed amongst the women who
underwent ovulation induction as can be seen from the
mean of approximately 3 completed cycles of induction.
It has been recommended that when an ovulatory dose of
any agent has been found, the patient should continue on
11
this for six months .
Despite evidence that weight loss significantly
improves pregnancy and ovulation rates in anovulatory
12,13
obese women , the women in this study showed poor
compliance with adjunctive treatment particularly
weight reduction and metformin therapy. Despite
counseling, our subjects were looking for quick results.
This probably accounts for the overall pregnancy rate of
38%, which is close to the 40% pregnancy rate recorded
11
by Speroff .
It was interesting that approximately half of the
pregnancies occurred spontaneously i.e. without any
medical treatment. Most interesting were those who
conceived spontaneously after discontinuing ovulation
induction. This confirms earlier opinions that women
2
with PCOS do ovulate, albeit irregularly . For those
Table 3 Ovulation induction agents used in 42
PCOS Nigerian women
HMG* = Human menopausal gonadotrophin
Induction agent(s)
Bromocryptine and clomiphene citrate
Clomiphene citrate and HMG*
Clomiphene citrate only
HMG* only
Tamoxifen with HMG*
Total
No
19
11
10
1
1
42
Percent
45.2
26.2
23.8
2.4
2.4
100.0
315
Nigerian Journal of Medicine, Vol. 22 No. 4, October - December, 2013, ISSN 1115 - 2613
who conceived after discontinuing ovulation induction,
it is tempting to speculate that the ovulation induction
agen t s mi g h t ha v e co r r e c te d s om e o f t h e
endocrinopathies which cause anovulation in PCOS
patients.
This study has some limitations. Insulin levels could not
be measured in the subjects. Additionally, hirsuitism
was not quantified in those in whom it was present.
Since not all the subjects presented with infertility, their
treatment precluded treatment for hirsuitism and other
manifestations of androgen excess.
We conclude that PCOS is fairly common occurring in
approximately one in six infertile Nigerian women.
Infertility, oligomenorrhoea, obesity, LH/FSH ratio > 2,
hyperprolactinaemia and hirsutism are the commonest
clinical features. On individualized management, about
two-fifths of them conceive either spontaneously or
following ovulation induction. A high default rate and
poor compliance to adjunctive treatment are constraints
to effective management of such women.
REFERENCES
1. Stein IF, Leventhal ML. Amenorrhoea associated
with bilateral polycystic ovaries. American Journal
of Obstetrics and Gynaecology 1935; 29:181-191.
2. Balen AH, MacDougall J, Jacobs HS. Polycystic
ovaries and their relevance to assisted conception.
In: Brinsden P.R. (Ed): A textbook of in vitro
fertilization and assisted reproduction, the Born Hall
nd
guide to clinical and laboratory practice, 2 ed, New
Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
2000:109-129.
3. Norma RJ, Wu R, Stankiewicz M. Polycystic ovary
syndrome. The Medical Journal of Australia 2004;
180 (3): 132-137.
4. Fauser BCJM. Revised 2003 Consensus on
diagnostic criteria and long-term health risks related
to Polycystic Ovary Syndrome (PCOS). Human
Reproduction 2004; 19(1): 41-47.
5. Balen AH, Laven JS, Tan SL, Dewailly D.
Ultrasound assessment of the polycystic ovary:
international consensus definitions. Human
Reproduction Update 2003; 9(6): 505-514.
6. Clayton RN, Ogden V, Hodgkinson J, Worswick L,
Rodin DA, Dyer S, Meade TW. How common are
polycystic ovaries in normal women and what is
their significance for the fertility of the population?
Clinical Endocrinology 1992; 37:127-134.
7. MacDougall JM, Tans SL, Hall V, Balen AH, Mason
BA, Jacobs HS. Comparison of natural with
clomiphene citrate stimulated cycles in IVF: a
prospective randomized trial. Fertil Steril 1994;
61:1052-1057.
8. Balen A. The current understanding of polycystic
ov a r y s yndr o m e. The Obst e t rici a n a nd
Gynaecologist 2004; 6:66-74.
9. Meniru GI. Complications of superovulation in
intrauterine insemination. In: Meniru GI, Brinsden
PR, Craft IL. (Eds). A handbook of intrauterine
insemination. Cambridge: Cambridge University
Press, 1997:207-233.
10. MacDougall JM, Tan SL, Balen AH, Jacobs HS. A
controlled study comparing patients with and
without polycystic ovaries undergoing in-vitro
fertilization and the ovarian hyperstimulation
syndrome. Human Reproduction 1993; 8:233-237.
11. Speroff L, Glass RH, Kase NG. Clinical
th
Gynecologic Endocrinology and Infertility. 5 Ed.
Baltimore, Maryland: Williams & Wilkins: 897-
930.
12. Clark AM, Ledger W, Galletly C, Tomlinson L,
Blaney F, Wang X, Norman RJ. Weight loss results
in significant improvement in pregnancy and
ovulation rates in anovulatory obese women.
Human Reproduction 1995; 10:2705-2712.
13. Clark AM, Thornley B, Tomlinson L, Galletley C,
Norman RJ. Weight loss in obese infertile women
results in improvement in reproductive outcome for
all f o r m s of fe r t i lity tr e a t m e n t . Human
Reproduction 1998; 13:1502-1505.
316
Nigerian Journal of Medicine, Vol. 22 No. 4, October - December, 2013, ISSN 1115 - 2613
