PCOS : Symptoms & Diagnosis

Pathogenesis (etiology?)

• Hypersecretion of adrenal androgens?

• Hypersecretion of ovarian androgens?

• A genetic disorder with an autosomal dominant mode of inheritance?

• A multifactorial genetic disorder?

• Insulin resisrance 50% decreased sensitivity to insulin in peripheral

tissues muscle and adipose tissue (but not in

hepatic tissue)

LH FSH

follicular maturation

Androgen excess

Extra glandular aromatization

Stim. Of stroma and theca

Chronic anovulation

Adipose tissue

acyclic estrogen

Adrenal androgen

Cyclic estrogen Ovarian androgen

Obesity

Insulin

Free testosterone

SHBG IGF-1

5-alfa reductase activity is stimulated

IGF*** insulin like growth factor

Presentation

(STEIN-LEVENTHAL SYNDROM)

• Amenorrhea ,Oligomenorrhea• Infertility• Hirsutism• Acne• OBESITY !

Other Symptoms

• “Dirty Skin” or Acanthosis Nigricans : This condition causes light brown to black rough patches around the neck and under arms.

• Migraines : Severe headaches that cause light sensitivity, nausea and dizziness.

Courtesy of www.mja.com

Androgen excess society 2006

All these factors :

• Hirsutism and/or hyperandrogenemia

•Oligoanovolution and/or polycystic ovaries

• Exclusion of androgen excess or related disorders

Increased LH secretion: ??•Ratio of LH/FSH 2-3

measurement of antimüllerian hormone (AMH) concentrations may be useful in the diagnosis/confirmation of PCOS, although data are inconclusive and its routine measurement is not currently recommended

Increased androgen levels in blood (testosterone , androstendione)

Increased LH, exaggerated surge Increased fasting insulin Increased estradiol and estrone

levels Decreased SHBG levels Slightly rise in DEHEAIncreased prolactin

serum testosterone undergoes episodic changes. Partly it is because norms are standardized for early morning on days 4 through 10 of the menstrual cycle in regularly cycling women because normal testosterone levels fall 10 percent from 8:00 AM to 4:00 PM and rise transiently during midcycle

ImagingImaging

• ultrasonographgy

number of cysts in ≥12 cysts with diameter of 2-9mm.

Long term risks in PCOS

• Type 2 diabetes • Dyslipidemia diminished HDL and increased LDL

• Endometrial cancer

• Hypertension

• Cardiovascular disease

• Gestational diabetes mellitus

• Ovarian cancer

Long term risks in PCOS

Treatment

Oral Contraceptives

contain two major hormones for ovulation : estrogen and progestin.

oral contraceptive pills (OCPs) interfere with the assessment of androgens. They suppress gonadotropins, elevate SHBG, and directly inhibit steroidogenic enzymes such as 3ß-hydroxysteroid dehydrogenase (3ß-HSD). They normalize androgens in PCOS

cuts the risk of endometrial cancer 50%.

If the woman is not hirsute and does not desire pregnancy:

periodic withdrawal menses ,with medroxyprogesterone acetate 10 days per month

decreasing peripheral estrogen formation (by weight reduction)

If pregnancy is desired

ovulation must be induced. Insulin-sensitizing drugs, such as metformin and the thiazolidinediones.

Clomiphene , letrozole

hMG, urofollitropin ,gonadorelin

•Laparoscopic electrocautery persistence of ovulation and normalization of serum androgens and SHBG over many years

effect on insulin resistance and serum lipids is not assessed