Polycystic ovarian syndrome

Remember//
increased androgen and ovulatory dysfunction

Definition
PCOS is a complex endocrine disorder affecting women of childbearing age
characterized by increased androgen production and ovulatory
dysfunction

Prevalence 6-8% of normal population

Leading cause of anovulatory infertility and hirsutism.

Women with PCOS have an increased risk of miscarriage, insulin

resistance, hyperlipidemia, type 2 diabetes, cardiovascular disease,
endometrial hyperplasia and endometrial cancer.

PCOS was first identified by Stein and Leventhal in 1935 (obesity and
infertity, with enlarged ovaries with multiple cysts)
Few of these original features are now considered consistent findings in
PCOS.

Aetiology
Unkown
But some contribute it to↓↓
Inherited genetic defect →→obesity and insulin resistance-
→→hyperinsulinaemia-→→hyperandrogenism through production in the
theca cell and through its suppressive effects on sex hormone binding
globulin production by the liver
Rotterdam Criteria (2 out of 3)
1-Menstrual irregularity due to anovulation oligo-ovulation

2-Evidence of clinical or biochemical hyperandrogenism

3-Polycystic ovaries by US

4-presence of 12 or more follicles in each ovary measuring 2 to 9 mm in

diameter and/or increased ovarian volume

In addition, other etiologies (congenital adrenal hyperplasias, androgen-

secreting tumors, Cushing's syndrome) must be excluded.

Hyperandrognism ↓↓↓
HIRSUTISM, ACNE, MALE PATTERN BALDING, ALOPECIA
50-90% PATIENTS HAVE ELEVATED SERUM ANDROGEN LEVELS
FREE TESTOSTERONE LEVELS MOST SENSITIVE
RARE: INCREASED MUSCLE MASS, DEEPENING VOICE, CLITORMEGALY
(SHOULD PROMPT SEARCH FOR UNDERLYING NEOPLASM)
OVARIAN ABNORMALITIES (SEEN BY
ULTRASOUND)

THICKENED SCLEROTIC CORTEX

MULTIPLE FOLLICLES IN PERIPHERAL LOCATION
80% OF WOMEN WITH PCOS HAVE CLASSIC CYSTS
LARGE VOLUME OVARIES
Ultrasound ↑ ↑ ↑ ↑multiple peripheral follicles//thick
cortex /large volume ovaries.
Clinical features
Obesity/ Incidence between 30-75 % /Mainly central obesity (barrel
shape woman)/Even thin women have excessive central adiposity

Infertility/ due to ovulation defect

Menstural distrubances Oligomenorrhoea or amenorrhoea

Symptoms of hyperandroginism
Like acne /hirsutism/male pattern balding/alopecia. Rarely ↑muscle mass,
deep voice, clitormegaly (search for androgen secreting tumor)

RISKS & COMPLICATIONS

-Recurrent miscarriage

-hyperlipidemia

-Type 2 Diabetes Mellitus

-Cardiovascular disease

-Endometrial hyperplasia (due to unopposed oestrogen)

- Endometrial cancer

DIFFERENTIAL DIAGNOSIS
1. Hyperprolactinemia
 Prominent menstrual dysfunction
 Little hyperandrogenism
2. Congenital Adrenal Hyperplasia
 morning serum 17-hydroxyprogesterone concentration greater
than 200 ng/dL in the early follicular phase strongly suggests
the diagnosis
  confirmed by a high dose (250 mcg) ACTH stimulation test:
post-ACTH serum 17-hydroxyprogesterone value less than
1000 ng/dL
3. Ovarian and adrenal tumors
 serum testosterone concentrations are always higher than 150
ng/dL
 adrenal tumors: serum DHEA-S concentrations higher than
800 mcg/dL
 LOW serum LH concentrations

4. Cushing’s syndrome
5. Drugs: danazol; OCPs with high androgenicity

Laboratory tests
 Serum HCG
 Serum prolactin
 Thyroid function test
 Reversed FSH/LH Ratio & high LH levels
 Serum estradiol—normal
 Serum estrone—elevated
 Fasting glucose: may be elevated
 2 hour OGTT: may be elevated
 Fasting insulin: elevated
 Free testosterone: elevated
 DHEA-S: normal
 17-hydroxyprogesterone: normal
 Lipids↑
Imaging test
Ultrasound (finding above)
TREATMENT
Depend on goal of treatment

Weight loss improves symptoms and help to return ovulation

and fertility
INSULIN SENSTIZING AGENT LIKE
METFORMIN
 For single patient or those who are not concerned about conception
→→ combined oral contraceptive pill
 For women concerned about conception clomphine citerate & if failed
→→gonadotrphins →→if failed →OVARIAN DRILLING→IF
FAILED→IVF
Hirustism treatment
Mechanical removal

COC with minimum androgens or COC plus androgens

Spirolactone

Antiandrogens e.g. like flutamide