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:

  • Most common metabolic\endocrine disorder in women.

  • Most common cause of secondary amenorrhea and oligomenorrhea.

  • Most common cause of hirsutism in clinical practice.

Causes and Risk Factors:

  • Obesity and\or insulin resistance.

  • Family history of polycystic ovaries or metabolic disorders.

  • Mexican-American ethnicity.

  • Premature menarche.​

  • Premature adrenarche.

  • Hyperandrogenism

  • Type 1, 2, gestational DM.

  • Antiepileptic drugs (for example, valproate)

  • DENND1A gene is linked to PCOS in many populations.

  Basic physiology (regulation of the ovaries):

  • Follicles contain oocyte, and the oocyte is surrounded by granulosa and theca cells.

  • GnRH acts on the anterior pituitary gland to produce LH and FSH.

  • LH works on theca cells to produce androgen.

  • LH stimulates ovulation, after ovulation, the residual follicle becomes corpus luteum, which will eventually degenerate if fertilization does not occur.

  • FSH stimulates granulosa to convert androgen into estradiol

Some studies suggets that PCOS is inherted in an autosomal dominnat pattern 

Clinical Presentation:

  • Menstrual abnormalities:

  • Oligomenorrhea and amenorrhea.

  • Hyperandrogenism:

  • Hirsutism,hair in a male distribution pattern.

  • Clitoromegaly, increased muscle mass and voice deepening.

  • Acne.

  • Alopecia.  

  • 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:

  • Thyroid function tests, serum prolactin levels, and a free androgen index to rule out other causes.

  • Ultrasounds:

  • 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:

  1. Treat hyperandrogenic symptoms like acne and hirsutism.

  2. Treat underlying metabolic disorders.

  3. Prevent complications like hyperplasia or carcinoma.

  4. Contraception for those who are not pursuing pregnancy.

  5. Ovulation induction for those who are pursuing pregnancy.

  • Lifestyle modifications:

            Diet, exercise for weight reduction.

Females not pursuing pregnancy:

  • First line treatment is Estrogen-progesterone combined oral contraceptive pills 20 mcg. Benefits include: endometrial protection, contraception and control of hyperandrogen symptoms.

  • If the hyperandrogeic symptoms do not resolve after 6 months, antiandrogens can be added. For example, spironolactone 50 to 100 mg twice daily.

  • Metformin to reduce insulin level.

  • Statin to reduce cholesterol.

Females pursuing pregnancy:

Ovulation induction:

  • Clomiphene citrate as first line therapy for non-obese women, if obese, then Letrozole is a choice.

  • In vitro fertilization.

Complications:

  • Metabolic issues:

             ✔ Insulin resistance
             ✔ Obesity
             ✔ Metabolic syndrome
             ✔ Non fatty liver disease
             ✔ DM type 2
             ✔ Dyslipidemia

  • Coronary heart disease.

  • Venous thrombosis.

  • Endometrial cancer.

  • Sleep apnea.

  • Depression and anxiety disorders. 

Avoid DRE & Prostate massage in acute prostatitis  because it may incduce bacterima 

References:

 

Written by:      Samaher AlHarbi       


Reviewed by:  Lama AlAlulah
                         AlWaleed AlYamani ​

Format editor:  Adel Yasky