POLYCYSTIC OVARY SYNDROME

CONTENTS INTRODUCTION ESSENTIAL COMPONENTS PATHOPHYSIOLOGY DIAGNOSTIC CRITERIA CLINICAL FEATURES DIFFERENTIAL DIAGNOSIS DIAGNOSIS MANAGEMENT

INTRODUCTION• Polycystic ovary syndrome (PCOS) is the most common cause

of infertility in women• Frequently seen in adolescence • Primarily characterized by ovulatory dysfunction &

hyperandrogenism• Consequences Increased risk for metabolic syndrome, type

2 diabetes mellitus, cardiovascular disease & endometrial carcinoma

• Prevalence of PCOS in Indian adolescents is 9.13%

Prevalence of polycystic ovarian syndrome in Indian adolescentsNidhi R, Padmalatha V, nagarathna R, Amirtanshu R. J. Pediatr. Adolesc Gynecol  2011 Aug;24(4):223-7.

• In 1935, Stein and Leventhal described 7 women with bilateral enlarged PCO, amenorrhea or irregular menses, infertility and masculinizing features.

• This paper introduced clinicians to the concept of reproductive endocrinopathies

Stein and Leventhal

Other names• Polycystic Ovarian Syndrome, • Functional Ovarian Hyperandrogenism, • Chronic Hyperandrogenic Anovulation, • Ovarian Hyperandrogenic Dysfunction, • Hirsutism-Anovulation Syndrome, • Stein Leventhal Syndrome, • PCO • PCOD • Polycystic Ovaries • Sclerocystic ovary • Stein’s Syndrome

ESSENTIAL COMPONENTS

POLYCYSTIC OVARY  

SYNDROME

 HYPERANDROGENISM

ANOVULATION 

OBESITY

POLYCYSTIC OVARIES ( ONE OR 

BOTH)

CLINICAL FINDINGS

• Cutaneous manifestations of hyperandrogenism

• Hirsuitism:- Commonly graded according to the Ferriman-Gallwey systemthe extent of hair growth in the most androgen-sensitive areas

• Acne :- Acne vulgaris is an important cutaneous manifestation of hyperandrogenemia in adolescents

• Seen in approximately one-third or more of PCOS patients

• Primarily affects the face, less often, the back and chest

• Androgenic Alopecia• Progressive, non-scarring, patterned loss of scalp

terminal hairs.• Male-pattern (affecting the fronto-temporo-occipital

scalp)• Female-pattern (affecting the crown. "Christmas

tree" pattern)

Ovarian findings

Obesity

• PCOS most common obesity-related endocrine syndrome in females

• Present in approximately one-half of patients.• Central (android) obesity is common• Defined by a waist circumference ≥88 cm in

adolescents as well as adult women

INSULIN RESISTANCE

• Commonly seen in adults with PCOS• Increased risk for glucose intolerance• Glucose tolerance progressively deteriorates over

time• Approximately 10% develop DM by 40 yrs of age• Clinical manifestations of insulin resistance include acanthosis nigricans & metabolic syndrome

• Acanthosis nigricans – Indicator of insulin resistance and may be the presenting complaint of patients with PCO

Metabolic syndrome • Results from the interaction of insulin resistance with

obesity and age• Co-occurrence of metabolic risk factors for type 2

diabetes & cardiovascular disease, including abdominal obesity, hyperglycemia, elevated triglycerides, low HDL cholesterol, and hypertension.

• Approximately 25 %of adolescents with PCOS have metabolic syndrome

Differential diagnosis

1. Virilizing congenital adrenal hyperplasia2. Cushing’s syndrome3. Virilizing tumors4. Hyperprolactinemia5. Insulin-resistance disorders6. Acromegaly7. Thyroid dysfunction8. Drugs

DIAGNOSIS

• History and physical examination

• Cutaneous manifestations of hyperandrogenism provide clinical evidence of hyperandrogenism

• History of medications

ULTRASONOGRAPHY Done to R/O rare but serious adrenal or ovarian

tumor & ovarian pathology not related to PCOS Determination of polycystic ovaries Pelvic pathology ovotesticular disorder of sex

development & functional hyperandrogenism of pregnancy -detected by ultrasonography

Patient reassurance and education

USG• B/L enlarged ovaries with

multiple small follicles• Peripheral location of

follicles:-string of pearl appearance

• 12 or more follicles measuring 2-9 mm

• Hyperechoic central stroma• Irregular ovarian outline

TESTING FOR HYPERANDROGENEMIA

• Done by testosterone levels• Total testosterone & Free testosterone• Normal upper limit for serum total testosterone in

adult women is approximately 40 to 60 ng/dL (1.4 to 2.1nmol/L)

• Serum testosterone concentrations 29 to 150 ng/dL (1.0 to 5.2 nmol/L)

• Total testosterone >200 ng/dL (6.9 nmol/L) 

• Dehydroepiandrosterone sulfate (DHEAS) –marker for adrenal hyperandrogenism

• Used to detect adrenal tumor• Adrenal tumorDHEAS levels are often markedly

elevated (>700 mcg/dL, 13.6 mmol/L)

Laboratory Tests

• FSH - will be normal or low with PCOS• LH (Lutenizing Hormone) - will be elevated• LH/FSH ratio - This ratio is normally about 1:1 in

premenopausal women, but with PCOS a ratio of greater than 2:1 or 3:1 may be considered diagnostic.

• Prolactin - will be normal or low (elevated in hyperprolactinemia)

• Estrogens - may be normal or elevated• hCG (Human chorionic gonadotropin) - used to check

for pregnancy; negative unless pregnant

• Lipid profile (low HDL, high LDL & cholesterol, elevated triglycerides)

• Glucose - fasting and/or a glucose tolerance test; may be elevated

• Insulin - often elevated• TSH (Thyroid stimulating hormone) - to check thyroid

function• Free cortisol & creatinine levels - rule out Cushings

syndrome• 17-hydroxyprogestrone- to rule out congenital

adrenal hyperplasia

                     MANAGEMENT

NON PHARMACOLOGICAL

• Nonpharmacologic measures are universally recommended.– These measures include the following(Lifestyle Measures):

Diet including seeing a dietician who is knowledgeable in PCOS

Exercise Weight Reduction if the patient is obese or insulin-

resistant.

Life style modification & weight loss in PCOD

• Risk modification and symptom relief (e.g., restoration of ovulatory cycles) has clearly been achieved with lifestyle modification and weight loss

• All strategies for weight loss, including surgery, need to be explored in PCOS patients.

• Combination of weight-reducing medications and group lifestyle modification was shown to be more effective than either alone, in a group of obese adults.

• Bariatric surgery as treatment for obesity is highly relevant to the PCOS population

• Shown to reverse much of the metabolic, as well as the reproductive problems , including hirsutism.

MEDICAL MANGEMENT

Oral contraceptive pills• 1st line treatment• Correct both menstrual abnormalities and

hyperandrogenemia• Estrogen-progestin combination suppresses the

hypothalamic-pituitary-ovarian axis & reduces excess androgen production by the ovary

• Progestin component inhibits endometrial proliferation →prevents hyperplasia and the associated risk of carcinoma

Limitations

• Fourfold increased risk of venous thromboembolism in first-time users

• Contraindicated in perimenarcheal girls with short stature- growth-inhibitory amounts of estrogen

• Belief of curative treatment and defer in follow-up• Do not permit conception if and when it is desired.

HIRSUITISM

• Not controlled satisfactorily within six months by the hormonal treatments→ additional methods used

• Cosmetic measures:- shaving, chemical depilatory agents, bleaching, and waxing techniques

• Eflornithine hydrochloride cream (Vaniqa) removal of unwanted facial hair in women.

• It inhibits hair growth and takes about six to eight weeks for clinical effect.

• It needs to be used indefinitely to prevent regrowth

Laser therapy:- Permanent hair removal by dermal papillae destruction

Electrolysis :- Permanent hair removal by dermal papillae destruction .

• Slow, expensive therapy that can occasionally cause scarring

Oral hypoglycemic agents

• Metformin :- Reduces insulin concentrations, promotes ovulation, and lowers androgen levels

• Does not improve hirsutism• Metformin tends to suppress appetite and slightly enhance

weight loss• Abnormal glucose tolerance is the only approved indication

for metformin• Lowers testosterone levels by 20 %

• A recent, uncontrolled, retrospective, observational study, shows that long-term treatment with metformin delays or prevents the development of impaired glucose tolerance and diabetes in women with PCOS

Sharma ST,Wickham III EP, Nestler JE. Changes in glucose tolerance with metformin treatment in polycystic ovary syndrome: a retrospective analysis. Endo. Prac. 13(4), 373-379 (2007). 

Laparoscopic surgery

• Surgical approaches to restoring ovulation in women with PCOS date back to the 1930

• B/l ovarian wedge resection used• Complications→ post op adhesion formation• Laproscopic surgery currently employed• Sr androstenedione ↓• Sr LH, testosterone, and inhibin concentrations ↓ • Sr FSH concentrations ↑

• Methods:- Electrocautery (also known as diathermy), laser "drilling," & multiple biopsy

Summarize

• Polycystic ovary syndrome (PCOS) is the most common cause of infertility in women

• Frequently seen in adolescence • Early diagnosis is important because of the

potential long-term consequences• Primarily characterized by ovulatory dysfunction

& hyperandrogenism• Diagnosis- USG abdomen showing polycystic

ovaries

• Management- Includes Non pharmacological( weight reduction, diet and exercise) & pharmacological ( Combined OCPs and Metformin)

• Surgery:- Electrocautery, laser drilling & multiple biopsy

September is PCOS Awareness Month

THANK YOU