Polycystic ovarian syndrome

Amila Weerasinghe
21st Batch
Faculty of Medical Sciences
University of Sri Jayewardenepura
Sri Lanka

05/04/2016
 Objectives
1. Introduction
2. Aetiology
3. Clinical features
4. Diagnosis
5. Management
6. Outcomes
 1. Introduction
• A syndrome of ovarian dysfunction
with
cardinal features of hyperandrogenism
polycystic ovary morphology

• Often complicated by chronic anovulatory infertility

• Clinical manifestations include oligomenorrhoea,

hirsutism and acne
• Many women are obese and have a higher
prevalence of
 impaired glucose tolerance,
 type 2 diabetes and
 sleep apnoea

• They exhibit an adverse cardiovascular risk

profile.
• Cardiometabolic syndrome as suggested by a
higher reported incidence of ,

hypertension

dyslipidaemia

 visceral obesity

insulin resistance

 hyperinsulinaemia
• Prevalence - 5 – 10 % of women of
reproductive age

• The commonest cause for anovulation (80%)

• USS evidence of polycystic ovaries in 20-30 %

of women

• The most common endocrine disorder in

women
 High risk groups

• Women with oligo ovulatory infertility

• Obesity and/or insulin resistance

• Type 1 , type 2 or gestational diabetes mellitus

• A history of premature adrenarche

• First-degree relatives with PCOS

• Women using antiepileptic drugs (valproate)

 2. Aetiology
• Not fully known
• No gene or specific environmental substance
has been identified.
• Genetic studies showed a link between PCOS and
metabolic disturbances such as disordered
insulin metabolism.

• Hence it may be a manifestation of a complex

genetic disorder.
• Selective insulin resistance may be central to the
aetiology of PCOS.

• Compensatory hyperinsulinaemia
• Decreased levels of serum hormone binding
globulin (SHBG)
• Trophic stimulus to androgen production in the
adrenals and ovaries
• Direct effect on the hypothalamus causing
abnormally stimulated appetite and increased
gonadotropin secretion
• Hypersecretion of LH

Stimulation of androgen secretion from

ovarian thecal cells

• Elevated LH : FSH ratio

 3.Clinical features
• Oligomenorrhoea / amenorrhoea - 75%
• Hirsutism
• Subfertility 75%
• Obesity 40%
• Recurrent miscarriage 50 – 60%
• Acanthosis nigricans
• Asymptomatic
 4.Diagnosis
2 out of 3 features of Rotterdam criteria
• Amenorrhoea/oligomenorrhoea (cycle >42 days)

• Clinical or biochemical hyperandrogenism

( acne, hirsutism,alopecia )

• Polycystic ovaries on ultrasound

( 8 or more subcapsular follicular cysts <10mm in
diameter and increased ovarian stroma)
 USS
• Bilateral enlargement of the ovaries > 8.0 cm.
Increased ovarian volume ( >10ml ).
• Thickened tunica albugenea
• Multiple small cysts (12 foliclles or lesser) of
0.2-0.9 cms in each ovary
• Absence of dominant follicle
• Thickened stroma (hyperthecosis)
• Resting or follicular endometrium
 Laboratory investigations:

• Demonstration of biochemical hyperandrogenaemia.

– Total testosterone (>200ng/dL)/ Free testosterone
> 2.2pg/mL.

• S. Estradiol and FSH estimations.

– Exclude hypogonadotropic hypogonadism
( E2, FSH).
– Exclude premature ovarian failure
( E2, FSH).
• S. Dehydroepiandrosterone sulfate.
– Not of value if S. Testosterone is normal
– Values > 430μg/dL significant. It is indicative
of adrenal source of androgens.
– Levels > 700 μg/mL suggestive of androgen
producing adrenal tumour.
• 24 hours urinary cortisol
– Cortisil < 50 μg/24 hours
– Exclude Cushing’s syndrome if patient is
hypertensive.
 Exclusion of other causes of
hyperandrogenism.
– Estimation of TSH to exclude thyroid dysfunction

– Estimation of serum prolactin to exclude

hyperprolactinemia

– Estimation of 17α hydroxyprogesterone.

Non classical congenital adrenal hyperplasia caused by

21-hydoxylase deficiency.
– Consider screening for Cushing’s syndrome,

and

– Rare conditions like acromegaly.

– Evaluation for metabolic syndrome X.

 5. Management
Treatment goals of polycystic ovary syndrome:

– Prevent endometrial hyperplasia, atypia/ cancer

– Restore normal ovulation / fertility

– Restore normal menstruation

– Correct hirsutism
 Aspects of management
1. Lifestyle modification
2. Improving menstrual regularity
3. Controlling symptoms of hyperandrogenism
4. Subfertility
5. Insulin sensitizers
6. Psychological issues
 1.Lifestyle modification
• Weight reduction through exercise and diet – the
most important step in managing overweight
women.

• Even a modest weight loss (5%) can improve

symptoms.

• Effective in restoring ovulatory cycles and

achieving pregnancy.
 2. Improving menstrual regularity

• Weight loss
• Combine oral contraceptive pills (COCP)
 inhibits LH
 Reduces circulating androgens
 increases circulating SHBG
Low dose combination pill containing low dose
of synthetic estrogen in combination with a low-
androgenic progestin
• Metformin
Benificial in patients with hyperinsulinaemia
and CVS risk factors.
Improves peripheral insulin sensitivity;
 improve ovulation rates
 improve glucose tolerance
 increased SHBG leading to reduced
bioavailability of androgens
 3. Controlling symptoms of
hyperandrogenism
• Mainly hirsutism

1st line treatment

Weight reduction
COCP
Medroxyprogesterone acetate
 2nd line treatment

Spironolactone
Cyproterone acetate
Finasteride
Flutamide
Eflornithine hydrochloride
GnRH agonists

Last resort

Ketoconazole
 Cosmetic approaches

Permenent
Laser
Electrolysis

Non-permanent
Local chemical depilatories
Bleaching
Waxing
Tweezing
Mechanical epilators
 4. Subfertility
• Weight loss
• Ovulation induction with antioestrogens or
gonadotrophins
Clomiphene citrate
Is a selective estrogen receptor modulator
1st line treatment in women with PCOS and
anovulatory infertility
Ovulation rate 70-80 %
Pregnancy rate 30-40 % over 6 cycles
• Laparoscopic ovarian diathermy

Effective in patients who are resistant to

clomiphine.
• In vitro fertilization ( IVF )
when ovulation can’t be achieved; or doesn’t
succeed in pregnancy.
 5. Insulin sensitizers
Metformin

• Metformin combined with clomiphene citrate

increases ovulation and pregnancy rates.
• No significant increase in birth rate.
• No significant improvement in acne or
hirsutism.
• Lowers androgen levels.
 6. Psychological issues
• Symptoms can be distressing and resulting
lower self esteem.

• Holistic approach
 Definite / common consequences of
PCOS
• Insulin resistance: Type-II diabetes

• Endometrial hyperplasia / atypia

• Gestational diabetes

• Sleep apnoea
 Possible consequences of PCOS

• Hypertension

• Coronary heart disease

• Dyslipidemia

• ? Risk of ovarian cancer

• ? Risk of abortion
Summary