‫سورة البقرة آيه ‪32‬‬

Polycystic ovarian disease

Described by Stein-Leventhal in 1953 and
include the syndrome (Amenorrhea or
Oligohypomenorrhea, Anovulation,
Hirsutism, Obesity and bilateral enlarged
polycystic ovaries).
Definition:
The ovary is enlarged 2 to 5
times the normal sizes and
characterized by a smooth
pearly white capsule.
 Prevalence of PCO
Using high-resolution ultrasound, PCO is
found in 92% of women with idiopathic
hirsutism, 87% with oligomenorrhea,
26% with amenorrhea, and 8-25% of
regularly cycles women.
 Clinical types of PCO
Pupertal PCO:
Manifestations appears at puberty with
persistent postmenarchal anovulatory
mens with obesity and hirsutism.
Post-pupertal PCO:
PCO appears after variable times of normal
menstrual function.
 Pathology
 The ovarian surface section shows a white,
thickened cortex with multiple microcysts less
than 1 cm in diameter.
 Polycystic ovary is a consequence of a state of
chronic persistent anovulation.
 Pathology
The characteristics of the ovary reflect
this dysfunctional state:
1. The surface area is doubled and the volume
increase of 2.8 times.
2. Increase in tunica thickness by 50%
3. The superficial cortex is fibrotic
4. The number of growing and atretic follicles
is doubled.
5. 1/3 increases in cortical stromal thickness
due to hyperplasia of theca cells and atresia.
6. 4 times increase of ovarian hilium cell nests
(hyperplasia).
 Pathology
1. Theca cell hyperactivity
The hyperplastic theca cells are the result of
chronic LH stimulation and associated
excessive androgen production
2. Granulosa cell inactivity
The follicular cysts do not mature fully, and
the absence of mature follicles results in
low estradiol production.
3. Chronic anovulation
Chronic anovulation is the end result of
inappropriate gonadotropin secretion,
hyperandrogenemia, hyperinsulinemia, and
hyperprolactinemia
 Long-term disease risk
 Abnormal lipid profiles (high triglycerides
and low HDL-cholesterol).
 Hyperinsulinemia, insulin resistance and
obesity are associated with an increased risk
of coronary heart disease.
 Increased prevalence of hypertension and
diabetes mellitus, when pregnancy occurs
 In persistently elevated estrogen levels there
is increase risk of endometrial carcinoma
and breast cancer.
 Genetic consideration
 The familial tendency of anovulation and
PCO suggests an underlying genetic basis
and X-linked dominant with paternal
transmission.
 Sisters and daughters may have a 50%
chance of having the same problems.
 Genes associated with a susceptibility to
anovulation and PCO have implicated a
focus on the insulin gene and the gene
encoding.
Insulin resistance, Hyperinsulinemia
 Hyperinsulinemia is defined as reduce
glucose response to a given amount of
insulin.
 The state of chronic hyperinsulinemia
represents a compensatory response to the
target tissue problem.
 The relation between serine
phosphorylation of the -chain of the
insulin receptor and the adrenals and
ovarian P450c17 enzyme has genetic bases.
 Diagnosis
Based on the clinical symptoms in the presence
of polycystic ovaries.
Clinical features
1. Anovulation
2. Oligomenorrhea and amenorrhea
3. Dysfunctional uterine bleeding in 30% of
affected females
4. Hyperandrogenism: 70% of' anovulatory
patients complain of hirsutism, alopecia,
seborrhea
5. Obesity and increase BMI are more
common in overweight anovulatory
women.
 Diagnosis
Endocrine disturbances
No single laboratory test can be expected to
fully discriminate women with PCOS
from healthy women.
1. Increase LH
2. Serum FSH may be low or low-
normal  elevated LH: FSH ratio
3. Elevated serum testosterone and
androstenedione in 50% of patients
4. Increased serum levels of DHEAS in
50% of patients.
 Pelvic Ultrasound
 The diagnosis of PCO is made when at
least 10 microcysts are seen using a
transabdominal ultrasound and 15
microcysts with transvaginal ultrasound.
 2-8 mm in diameter arranged around a
dense stroma (necklace of pearls) or
scattered throughout an abundant stroma.
Pelvic Ultrasound
 Doppler Ultrasound
Polycystic ovaries show typical vascular
pattern:
• Increased ovarian stromal vascularity
• Positive correlation between increased
blood velocities and serum LH levels
• Lower resistance index (RI) and
pulsatility index (PI) values
• Increased resistance index and
pulsatility index values of uterine
arteries.
 Differential diagnosis
1. Adrenal hyperplasia. & Cushing Syn.
2. Ovarian hyperthecosis: Islets of lutenized
theca cells in stroma. It is a sever form of
PCO syndrome with high androgen level
(tumor level). Clomid is ineffective, but
wedge resection or partial excision may be
helpful.
3. Androgen producing ovarian tumors.
4. Thyroid disease (Myxodema).
5. Hyperprolactinaemia syndrome.
 Management
Establishing cyclic ovulation can be
accomplished in most cases and should be
the primary consideration. However,
treatment depends on a patient's goals.
Clinical problem Treatment Options
Oligomenorrhea 1. Oral contraceptive pills
2. Progesterone.
Obesity 1. Diet control and regimen.

Hirsutism 1. Oral contraceptive pills.

2. Corticosteroids.

3. Gn-Rh agonist analogs.

4. Other drugs

5. Cosmetics
Anovulation 1. Clomid
2. Tamoxifen.
Treatment of hyperandrogenism
1. Weight loss
2. Oral contraceptive pills
3. Medroxyprogesterone acetate (MPA)
4. GNRH agonists
5. Glucocorticoids
6. Spironolactone
7. Flutamide
8. Cimetidine
9. Finasteride
10. Laparoscopic electrocautery
11. Physical methods of hair removal
Medical therapy for anovulation
 Hypersecretion of LH is associated
particularly with menstrual disturbances
and infertility.
 This endocrine feature result in reduced
conception rates and increased rates of
miscarriage in both natural and assisted
conception.
1. Clomiphene citrate
2. Tamoxifen
3. Gonadotrophine therapy
4. GnRH analogues
Surgical therapy for anovulation
Laparoscopic ovarian diathermy:
 The ovarian surface is fulgurated using a
bipolar needle electrode inserted
perpendicular to the ovarian surface.
 After drilling, liberal irrigation of the
pelvic cavity should be done to cool the
ovary before releasing it free in the pelvis
and to remove necrotic debris and carbon
particles.
Surgical therapy for anovulation
Laparoscopic ovarian diathermy:
 The number of holes created per ovary
depends on the size of the ovary and the
numbers vary from 4 to 20 holes per
ovary with coagulating current, holes of
approximately 3-4 mm in diameter and 2-
8 mm in depth are created.
Laparoscopic laser ovarian drilling
More recently, the carbon dioxide-nitrogen-
helium (CO2) and the flexible fiber lasers
as neodymium have been used.
Laparoscopic ovarian diathermy