Polycystic Ovarian Syndrome

Common disease occurs in 12-20% of females

Etiology is unclear; PCOS due to inappropriate GnRh secretion and
ovarian hormonal dysfunction.

Presentation
2 main presentations: early presentation late onset (usually after putting on
weight & becoming obese)

Early presentation is typically: menarche with a few regular periods;

periods then become more infrequent and irregular

Rotterdam criteria for diagnosis:

1.

2.

2.

Oligo/ anovulation
a.
Evidence of cycles> 35 days or no
periods
b.
Infertility
Hyperandrogenism
a.
Clinical evidence of hirsuitism/ male
pattern hairloss
b.
Biochemical evidence of elevated
testosterone
Cyst
a.
Ultrasound evidence >10 cysts per

Other Features of PCOS:

Psychological symptoms:
Anxiety
Depression
Psychosexual dysfunction
Eating disorders
Metabolic symptoms
Obesity
Diabetes
Hyperlipidaemia
Acne

Investigations

Free Testosterone levels

o In the follicular phase - if a cycle is present
o (>3 months after stopping hormonal therapies)
Pelvic ultrasound
o Day 3-5
o Polycystic ovaries
May also be present in normal women or other
endocrinopathies: CAH, hyperprolactinaemia, hypothalamic
amenorrhoea
Luteal phase progesterone measurement
o Day 20-24 of menstrual cycle
To assess whether the patient has anovulation (even with
regular periods)/ if infertile.

Assess metabolic risk

Oral glucose tolerance test

Fasting lipid panel

Rule out other DDxs:

Look for other hormonal imbalance- as any hormone imbalance can

cause irregular menstruation
o TSH, FSH, LH, GH, prolactin, cortisol
Serum 17-hydroxyprogesterone
Exclude 21-hydroxylase-deficient non-classic adrenal hyperplasia
(late-onset)
Exclude androgen-XS disorders

Treatment
(ask the patient: if I could take one thing of your PCOS, what would it
be?)
Lifestyle measures
Weight loss: reduced androgen production (really effective!!)
Irregular menstrual cycles

Give combined oral contraceptive pill (COCP) to normalise menstrual

cycles & give withdrawal bleeds

Intermittent progestin every 3 months for withdrawal bleed & to

protect endometrium from hyperplasia (which can lead to cancer)
Hirsutism
Localised hirsutism:

Laser

Electrolysis

Topical eflornithine- inhibits cell

proliferation and function
Widespread hirsutism:

COCP (weigh up against other risks:

weight, age, thromboembolic risk they are obese!!!)

Other oestrogen- products

Spironolactone
Ferriman-gallwey score. Normal

Antiandrogen at higher doses (506-8

100mg BD)

Adverse effects: hyperkalaemia,

gynaecomastia, erectile dysfunction (males), skin rashes

Cyproterone acetate

Potent antiandrogen

Adverse effects: Hepatotoxic, teratogen

Menstrual cycles/ Infertility

Clomifene
o
Inhibits oestrogen receptors in the hypothalamus
Usually given early in the cycle (day 3-8)

Low oestrogen levels stimulate the GnRH HPO axis

increased LH & FSH secretion
Adverse effects: ovarian enlargement, visual disturbances, headaches, eye
floaters, sensitivity to light
Metformin
Reduces liver gluconeogenesis
Increases peripheral tissue glucose uptake
Adverse effects: GI side effects: diarrhoea, cramps, increased
flatulence, nausea & vomiting

DDxs:
- 21- hydroxylase deficiency:
o Insufficient 21-OH enzyme
accumulation of androgenic precursors
o Increased androgens
- Hypothyroidism
- Hyperprolactinaemia
- Acromegaly
- Cushing syndrome
- Hyperthyroidism
- Ovarian tumours

Take away points:

2 components to PCOS:
1.
Insulin resistance ->
reduced sex hormonebinding globulin (SHBG)> increased free
testosterone
2.
Testosterone/oestroge
n imbalance
Main concern with PCOS
Metabolic syndrome

Diabetes

Obesity

Dyslipidaemia
This may contribute to
increased risk of CVD and
complications in the future!!!

Case study:
24 year old girl comes into clinic with a history of irregular infrequent periods and
male- pattern hair loss.
She states that she has only had 5 periods in her whole life. She was much
heavier earlier on but was able to lose 7 kg. After losing this weight (through diet
& exercise), she had 3 periods- of varying lengths (ranging from 10 days- 3
weeks). She has previously been on the pill and implanon to try to regulate her
periods to no avail. Her gynaecologist is suggesting her to try Mirena to regulate
her periods. Recent ultrasound shows evidence of cysts on her ovaries.
She had a troublesome childhood and does not know her real birth mother who
may have had PCOS. She sometimes experiences anxiety attacks at work which
are getting worse.
O/E- young female with healthy body habitus (non-obese) with no OBVIOUS
evidence of hirsutism (a lot of effort goes into maintaining cosmetic aesthetics).
There was hair on her tummy (beneath umbilicus), on her breasts, down to her
thighs and bottom. She also had substantial hair on her upper lip and on her
chin. Ferriman-Gallwey score = 21.
?PCOS
?CAH
?21-OHase deficiency

Main problem: hirsutism

Has tried spironolactone in the past (100mg once daily for 1 year) with no
significant changes
Was placed on cyproterone (anti-androgenic medication)usually given
day 21 of cycle