POLYCYSTIC OVARIAN

SYNDROME
BY
AHMED MAGDY MAHMOUD
DEFINITION

• A chronic syndrome characterized by persistent ovulatory dysfunction and loss of normal hormonal
cyclicity.
• It was first described by Stein & leventhal 1935.
• It is the most common cause of amenorrhea, chronic anovulation , hirsutism and infertility.
PREVALENCE

• Affects around 4-6% of female in reproductive age.

• Etiology is unknown but genetic and familial tendency may play a role.
PATHOPHYSIOLOGY
• A vicious cycle may occur due to primary CNS error with HPO dysfunction or primary enzymatic error in
the ovary or adrenal.
• There is high LH pulse/ frequency that stimulates androgen production by theca cells and ovarian
stroma and inhibit aromatase enzyme that converts androgen to estradiol.
• This will lead to hyperandrogenism which leads to arrest of follicular development at various stages and
thickening of the capsule , multiple subcapsular cysts with no corpus leading to anovulation and
infertility , there also will be peripheral conversion of androgen to E1.
• The increase in E1 level has a positive feed back on LH and negative feed back on FSH hormone leading
to a vicious cycle.
PATHOLOGY

• Uterus
Symmetrically enlarged and later on may lead to endometrial hyperplasia
• Ovaries
Size ; enlarged 2-4 times
Tunica albuginea ; thick , ivory white and smooth ( no ovulation )
Cysts ; multiple , small , subcapsular and filled with clear fluid.
Stroma ; hyperplasia of theca and stroma cells.
DIAGNOSIS
Suggestive clinical picture
Symptoms
- Anovulation (periods of amen /oligo-hypomenorrhea followed by
prolonged painless irregular bleeding).
- Infertility ± habitual abortion (probably due to the high LH).
- Hirsutism & acne (hyperandrogenism) — 70%, acanthosis nigricans .
- Obesity — 50%: (obesity = BMI > 27 kg/m2) .
Signs
Symmetrically enlarged uterus
Bilateral enlarged ovaries
Ultrasonic criteria suggestive of PCO (Adams criteria)
-12 subcapsular cystic follicles (Necklace appearance )
- Each cyst is 2-9 mm in diameter.
- The whole ovarian volume is increased > 10 cm3.
Specific hormonal changes
Increased LH , Decreased FSH with LH/FSH ratio more than 2.5.
Increased Androgens (testosterone, androstenedione, DHEA-S)
Increased Estrogens (E1 mainly)
Increased Prolactin (<30 ng/ml)
Increased Insulin —> hyperinsulinemia (fasting glucose / insulin ratio > 4.5)
Decreased Progesterone (mid-luteal) = anovulation
Decreased Sex hormone binding globulin (SHBG)
ROTTERDAM CRITERIA

According to ESHRE (European Society for Human reproduction and embryology and
(American society for reproductive medicine); the presence of 2 or more of:-
1- Clinical and biochemical hyperandrogenism.
2- Oligo or anovulation and menstrual dysfunction.
3- Ovarian size and morphology on ultrasound
Ultrasound alone is not sufficient for diagnosing PCO. These findings are
Normal in 25% (polycystic like ovaries)
In diagnosis of PCOS: Other causes of androgen excess must be excluded
PCOS is a diagnosis of exclusion after eliminating other causes of
anovulation (e.g. thyroid diseases and hyperprolactinemia)
 LONG TERM RISKS OF PCOS

- Endometrial hyperplasia ± carcinoma

- Type II DM & hypertension
- Dyslipidemia (Decreased HDL, Increased LDL, Increased triglycerides) which increase liability to
coronary heart diseases .
TREATMENT

• General measures
1. Weight reduction: decreased hyperinsulinemia and hyperandrogenism.
2. Smoking is withheld as it increases adrenal androgen.
3. Oral hypoglycemic agents (e.g. metformin 500 mg / 8 hours): to decrease insulin resistance, LH
secretion and free testosterone.
• If pregnancy is desired
1. Medical ; induction of ovulation by either clomiphene citrate with or without ( HCG, bromocriptine or oral
hypoglycemic ).
2. Surgical ; If medical treatment fail or there is a risk of OHSS.
Done via bilateral laparoscopic ovarian drilling (cauterization)
- 4-8 punctures in each ovary for 2-4 seconds each
- Pregnancy rate up to 70 %
- Mechanism of action is unknown but may be due to:
.Removal of part of theca cells —> reduction of androgens
.Change in certain intraovarian paracrine factors
3. ART ; If all other measures fail.
If pregnancy is not desired
If the main complaint is irregular uterine bleeding
1. Medical
- COC: 21 days —> stop 7 days —> repeat
- Progesterone
Provera (medroxy progesterone acetate) 10 mg
Prevents also endometrial hyperplasia due to unopposed estrogen
2. D & C
- Therapeutic —> if medical therapy failed
- Diagnostic —> to exclude endometrial hyperplasia & malignancy
3. Hysterectomy
- After long term follow-up; if there is
Atypical hyperplasia OR Endometrial carcinoma
In old patient —> with failed medical therapy and D&C
If the main complaint is hirsutism
COC ; containing 3rd generation progesterone.
Diane ; containing EE and cyproterone acetate.
Hair removal by LASER.
Corticosteroids.
THANK YOU