How the widening definitions and over-prescription is done?

This prevalence was not the case a few decades back. “In 2019, everyone knows someone who is dealing with PCOS-related symptoms,” Dr. Pepalla says. “Ten years back, I used to get a maximum of one or two cases every month. Now, we see five to ten cases every two days.” This works out to hundreds of cases a month at a single clinic.

General Awareness on both the sides

This increased prevalence is attributed to increased awareness. “We are definitely seeing more cases, but that could be because of general awareness in both the doctor and patient community,” says Dr. Duru Shah, president of the PCOS Society of India. “In the 1990s, if I prescribed metformin to a woman with PCOS, after learning it is a diabetes medication, they used to distrust my expertise. That has changed.”

The year 1990 was a turning point in PCOS management. A National Institutes of Health conference in the US declared irregular menstruation and hyperandrogenism (excess androgens) to be the basis of the core diagnosis of PCOS. Then, in 2003, another conference in Rotterdam issued a further criterion—conducting an ultrasound for the presence of polycystic ovaries.

This broadened the population of women who meet the PCOS criteria. According to an Indian community study in Mumbai, the prevalence of PCOS shot up from 10.7% to 22.5%—over 1 in 5 women—under the new criteria. The need for an ultrasound, though, still remains debatable, as polycystic ovaries are seen in women without PCOS and there is no clear line that divides normal variability from the abnormality of PCOS, especially in young women.

Doing Envelope Calculations

This is important because if the one in five numbers is true, back of the envelope calculations point to a whopping 12 million PCOS cases in urban India alone. And if about 70% of women with PCOS are overweight and likely be categorized as at risk of developing type 2 diabetes, it means 8 million women in India are pre-diabetic; this is a huge prescription market.

Similarly, women who exhibit mild PCOS symptoms are still labeled as “at-risk” of cardiovascular disorders (CVD) or infertility and are medicated, even if they don’t need it. The psychological manifestations of labels in diagnosis are also enormous. These women may end up with anxiety, depression and body-image issues—another market.

A Mumbai-based OB/GYN and laparoscopic surgeon, speaking on condition of anonymity, said, “When it comes to PCOS, as a doctor community we are not aligned on a definitive treatment plan. Neither have we set up prospective clinical trials to see the correlation of these illnesses with PCOS nor do we have any evidence from retrospective research that proves PCOS was responsible for causing diabetes, CVD, infertility or certain cancers.”

He believes that understanding the cause rather than mindless medicating should be the medical fraternity’s priority. Something that was a paragraph in a gynecology textbook a decade ago is now systematically put in as a chapter, which only focuses on the treatment despite the lack of information on causality. So is PCOS pharma-driven hogwash?

“Consider this, obesity was deemed as one of the main factors [of PCOS], but now we’re learning a debatable concept called lean PCOS and are asked to prescribe another class of diabetes medication such as inositol. We are holding national conferences sponsored by the pharma companies and prescribing medicines to low-risk patients while they develop a dependency or consume daily pills at a young age, all to feed the pharma market. How is that responsible?” he concludes.

And it is not just the pharma industry that is opening its doors to a booming market.

What about various disciplines?

PCOS management involves various disciplines and industries. A single patient could visit a string of medical professionals, from general physicians to endocrinologists, gynecologists, fertility specialists, sonologists, psychologists, nutritionists, and dermatologists. All of this happens through various diagnostic, pharmaceutical, cosmeceutical and nutraceutical touchpoints.

Then there are alternative medicines—the likes of naturopathy, homeopathy, and Ayurveda—that attract women who are wary of side-effects from conventional medications. All of this makes PCOS an extremely expensive proposition for patients and an extremely lucrative one for any of the various PCOS treatment touchpoints.

 

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