Polycystic Ovarian Syndrome
Study guide:
Defnition:
Heterogeneous disorder that includes androgen excess, ovulatory dysfunction, and\or polycystic ovaries.
Also known as Stein-Leventhal Syndrome.
Epidemiology:
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Most common metabolic\endocrine disorder in women.
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Most common cause of secondary amenorrhea and oligomenorrhea.
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Most common cause of hirsutism in clinical practice.
Causes and Risk Factors:
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Obesity and\or insulin resistance.
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Family history of polycystic ovaries or metabolic disorders.
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Mexican-American ethnicity.
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Premature menarche.
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Premature adrenarche.
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Hyperandrogenism
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Type 1, 2, gestational DM.
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Antiepileptic drugs (for example, valproate)
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DENND1A gene is linked to PCOS in many populations.
Basic physiology (regulation of the ovaries):
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Follicles contain oocyte, and the oocyte is surrounded by granulosa and theca cells.
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GnRH acts on the anterior pituitary gland to produce LH and FSH.
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LH works on theca cells to produce androgen.
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LH stimulates ovulation, after ovulation, the residual follicle becomes corpus luteum, which will eventually degenerate if fertilization does not occur.
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FSH stimulates granulosa to convert androgen into estradiol
Some studies suggets that PCOS is inherted in an autosomal dominnat pattern


Clinical Presentation:
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Menstrual abnormalities:
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Oligomenorrhea and amenorrhea.
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Hyperandrogenism:
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Hirsutism,hair in a male distribution pattern.
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Clitoromegaly, increased muscle mass and voice deepening.
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Acne.
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Alopecia.
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Obesity, metabolic disorders, DM and acanthosis nigricans.
Diagnosis:
Rotterdam criteria 2003
2 out of 3 required for diagnosis of PCOS
1. Oligo or anovulation.
2. Clinical and/or biochemical signs of hyperandrogenism.
3. Evidence of PCOS on ultrasound.
*Although there are several proposed diagnostic criteria for polycystic ovary syndrome (PCOS), we agree with a summary report from a 2012 National Institutes of Health Workshop and suggest that the Rotterdam 2003 criteria be used for now.
Investigations:
Lab works:
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Thyroid function tests, serum prolactin levels, and a free androgen index to rule out other causes.
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Ultrasounds:
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Presence of 12 or more follicles in each ovary measuring
- 2 to 9 mm in diameter and/or increased ovarian volume.
- Pearl string appearance
Management:
Goals:
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Treat hyperandrogenic symptoms like acne and hirsutism.
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Treat underlying metabolic disorders.
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Prevent complications like hyperplasia or carcinoma.
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Contraception for those who are not pursuing pregnancy.
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Ovulation induction for those who are pursuing pregnancy.
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Lifestyle modifications:
Diet, exercise for weight reduction.
Females not pursuing pregnancy:
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First line treatment is Estrogen-progesterone combined oral contraceptive pills 20 mcg. Benefits include: endometrial protection, contraception and control of hyperandrogen symptoms.
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If the hyperandrogeic symptoms do not resolve after 6 months, antiandrogens can be added. For example, spironolactone 50 to 100 mg twice daily.
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Metformin to reduce insulin level.
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Statin to reduce cholesterol.
Females pursuing pregnancy:
Ovulation induction:
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Clomiphene citrate as first line therapy for non-obese women, if obese, then Letrozole is a choice.
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In vitro fertilization.
Complications:
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Metabolic issues:
✔ Insulin resistance
✔ Obesity
✔ Metabolic syndrome
✔ Non fatty liver disease
✔ DM type 2
✔ Dyslipidemia
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Coronary heart disease.
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Venous thrombosis.
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Endometrial cancer.
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Sleep apnea.
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Depression and anxiety disorders.
Avoid DRE & Prostate massage in acute prostatitis because it may incduce bacterima

References:
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Cecil, R., Goldman, L., & Schafer, A. Goldman's Cecil medicine.
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Le, T., &Bhushan, V.First aid for the USMLE step 1 2014.
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Uptodate.com,. (2015). Pathophysiology and etiology of polycystic ovary syndrome in adolescents. Retrieved 10 November 2015, from http://www.uptodate.com/contents/pathophysiology-and-etiology-of-polycystic-ovary-syndrome-in-adolescents#H27
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Uptodate.com,. (2015). Epidemiology and pathogenesis of the polycystic ovary syndrome in adults. Retrieved 10 November 2015, from http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-the-polycystic-ovary-syndrome-in-adults
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Uptodate.com,. (2015). Pathogenesis PCOS. Retrieved 10 November 2015, from http://www.uptodate.com/contents/image?imageKey=ENDO/64337&topicKey=ENDO%2F7430&source=outline_link
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Uptodate.com,. (2015). Clinical manifestations of polycystic ovary syndrome in adults. Retrieved 10 November 2015, from http://www.uptodate.com/contents/clinical-manifestations-of-polycystic-ovary-syndrome-in-adults#H342301178
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Uptodate.com,. (2015). Diagnosis of polycystic ovary syndrome in adults. Retrieved 10 November 2015, from http://www.uptodate.com/contents/diagnosis-of-polycystic-ovary-syndrome-in-adults
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Uptodate.com,. (2015). Diagnostic criteria PCOS. Retrieved 10 November 2015, from http://www.uptodate.com/contents/image?imageKey=ENDO%2F86810&topicKey=ENDO%2F7385&source=see_link
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Uptodate.com,. (2015). Treatment of polycystic ovary syndrome in adults. Retrieved 10 November 2015, from http://www.uptodate.com/contents/treatment-of-polycystic-ovary-syndrome-in-adults#H1586430
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Emedicine.medscape.com,. 'Polycystic Ovarian Syndrome: Practice Essentials, Background, Etiology'. N.p., 2015. Web. 26 Nov. 2015.
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https://www.biog1445.org/demo/07/ovaryplacenta.html (Figure 1).
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http://www.pathophys.org/pcos/ (Figure 2).
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http://permanence.com.au/our-treatments/pcos/ (Figure 3).
Written by: Samaher AlHarbi
Reviewed by: Lama AlAlulah
AlWaleed AlYamani
Format editor: Adel Yasky