Polycystic Ovarian Syndrome (PCOS)

Mira Aubuchon MD
Basics
Description
The cardinal features of PCOS have been described by international consensus and
consist of ovarian dysfunction alon !ith hyperandroenism and polycystic ovary
(PCO) morpholoy" PCOS is a syndrome and# as such# no sinle dianostic criterion
is sufficient for clinical dianosis"
Chronic hyperandroenic anovulation
$nsulin%resistant state
Ae%&elated 'actors
(sually postmenarchal and premenopausal
)pidemioloy
*+,-. of reproductive%ae !omen
/*. obese# 0*. lean
&is1 'actors
2arely un1no!n
3eiht ain
'amilial45enetic component
5enetics
6ih association of PCOS in sisters of PCOS patients
Possible altered ene near insulin receptor (chromosome ,7p,8"0)
Pathophysioloy
Altered 5n&6 secretion# disordered pituitary 26 and 'S69
o $mpaired ovarian folliculoenesis and anovulation# unopposed estroen
o 6yperandroenism and hirsutism9
Decreased liver S6B5
Adipose aromati:es to estroen# endometrial hyperplasia ris1
$nsulin resistance and pancreatic cell dysfunction9
o $ncreased theca cell androens perpetuate ovarian dysfunction
o $ncreased $5', decreases liver S6B5# !orsens hirsutism
Associated Conditions
Obesity (See Diet9 Obesity")
$nfertility (see topic)
6irsutism (see topic)
Acne
)ndometrial hyperplasia and cancer (See )ndometrial 6yperplasia and
)ndometrial Cancer")
Depression
Sleep disorders (see topic)
6ypertension (see topic)
$nsulin resistance
DM Type 0
Metabolic syndrome (see topic)
Cardiovascular disease
Dianosis
Sins and Symptoms
6istory
Olio%ovulation9
o Amenorrhea (see chapter)
o Oliomenorrhea (See Bleedin# Abnormal (terine9 Oliomenorrhea")
o Menorrhaia46eavy bleedin (See Bleedin# Abnormal (terine9 6eavy
Menstrual Bleedin")
Midline hair ro!th# acne# hair thinnin or loss# voice chanes
$nfertility# desire for fertility
6istory of estational DM or 6T;
Over!eiht4Obesity43eiht ain
'amily history DM or cardiovascular disease
$ndividual oals for treatment
&evie! of Systems
Mood# appetite# enery# sleep
3eiht and diet
Physical )<am
BP# pulse# heiht# !eiht# BM$# !aist circumference# hip circumference#
!aist9hip ratio
Thyroid9 ;odules# enlarement
S1in9
o Acanthosis niricans# acne# hirsutism# baldin# s1in tas
Breast9 5alactorrhea
Abdomen9 Masses or oranomealy
)<tremities9 )dema# DT&s
5(9 Clitoromealy# adne<al masses
Tests
&otterdam Criteria (048 !ith other causes of hyperandroenism e<cluded)9
Olio% or anovulation
Clinical and4or biochemical sins of hyperandroenism
PCO (on (S)
2abs
Prenancy test
Clinical criteria may be sufficient# !ith labs to rule out other causes
TS6# 'ree T=# prolactin# D6)AS# total testosterone# ,/%hydro<yproesterone
'astin lipids# lucose and 0%hour 5TT after /*%m load
;o loner considered useful9
o 269'S6 ratio (pulsatile# can be normal in PCOS)
o 'astin lucose9insulin ratio (can miss lucose tolerance aberrations)
$main

T>(9 ?,0 antral (@,- mm) follicles on a sinle ovary or ovarian volume ?,-
cm
8

)ndometrial thic1ness
Differential Dianosis
Prenancy
Prolactinoma
Thyroid dysfunction (See Thyroid Disease")
Androen%secretin tumor (See Ovarian Tumors# >irili:in")
Adrenal en:yme defect9
o 2ate onset CA6 (See Conenital Adrenal 6yperplasia")
CushinAs disease
Metabolic4)ndocrine
$mpaired fastin lucose ($'5)9
o ?,-- m4d2
$mpaired lucose tolerance ($5T)9
o 0%hour lucose ?,=- m4d2
DM9
o 5lucose fastin ?,0B m4d2 or 0%hour ?0-- m4d2
Metabolic syndrome (8 or more of)9
o 3C ?C* cm (8* in)
o $5T or $'5
o SBP D,=- mm 6 or DBP DC* mm 6
o Trilycerides D,*- m4d2
o 6D2 cholesterol @*- m4d2
Tumor4Malinancy
&is1 of endometrial hyperplasia and malinancy
Consider endometrial biopsy9
o (S )C ?7 mm
o @0 menses4year
Treatment
5eneral Measures
$f over!eiht or obese9
*+,-. !eiht loss to improve ovulation# hirsutism# fertility# prenancy safety
Calorie restriction# 8- minutes of viorous e<ercise * times a !ee1
$f $5T# lifestyle modification better than medication at preventin DM and
metabolic syndrome
Medication (Drus)
)ndometrial protection9 OCPs (monitor lipids and BP) or proestin
!ithdra!al every 8+= months
6irsutism control (try modalities for B months)
o OCPs
o Antiandroens (use contraception)
Spironolactone ,--+0-- m4d (monitor electrolytes)
'lutamide ,8-+*-- m4d (hepatoto<icity)
o )flornithine cream (>aniEa)9 b"i"d" only on face
o &osilita:one (=+C m4d)9 Mild improvement9
Monitor electrolytes# 1idney# liver function
F 3eiht ain (!ater retention)
P",*7
Metabolic (controversial for adolescents)9
o Metformin 6Cl ,#*-- m+0#--- m4d for prevention of DM and
metabolic syndrome if $5T9
;ausea# diarrhea# fatiue# F !eiht lossG start *-- m and
increase slo!ly
&are%lactic acidosisG Monitor electrolytes# liver# 1idney every
B+,0 months
6old dru for surery or contrast dye
Prenancy Considerations
Ovulation $nduction !ith timed intercourse# intrauterine insemination# or $>'
$nsulin sensiti:ers# alone or !ith clomiphene9
o Metformin ,#*-- m4d (Cateory B)9
May improve miscarriae rate if continued durin prenancy
(but studies are small)
o &osilita:one =+C m4d (Cateory C)
Clomiphene citrate# *-+0-- m4d# =+B cycles9
o Cycle days 8+/ or *+7
o Alone or !ith insulin sensiti:er
o C+,-. multiple prenancy rate
o >asomotor effects# visual symptoms (d4c)
Aromatase inhibitors (2etro:ole)9 * m4d# =+B cycles (use instead of
clomiphene controversial)
5onadotropin inHections# 'S6 or 269
o 0-+8-. multiple prenancy rate
o 6iher ris1 of ovarian hyperstimulation syndrome
Surery
Ovarian drillin4diathermy via laparoscopy9
Similar live birth rates to onadotropin inHections
o Temporary (B months) spontaneous ovulation
o &is1 of adhesion formation
'ollo!up
Disposition
$ssues for &eferral
Consider referral for nutrition4dietary counselin
May need specialist for manaement of cardiovascular ris1s9
o 6yperlipidemia
o 6T;
o DM
May need to consult dermatoloy9
o Moderate%severe acne !ith scarrin
6air removal9
o )lectrolysis is only permanent method
o 2aser is lon%lastin
o Depilatories# bleachin# !a<in# shavin for hirsutism
Pronosis
3ith appropriate dianosis and manaement# symptoms can be controlled"
Surveillance and active manaement may minimi:e cardiovascular ris1s"
Treatment !ith OCPs or proestin can minimi:e menstrual irreularities and
decrease ris1s of endometrial cancer"
Patient Monitorin
2ipids every year if abnormal
'astin lucose and 0%hour 5TT every 8 years
Monitor menses# BP# !eiht# 3C every B months to , year
Biblioraphy
2ero &S# et al" Detectin insulin resistance in polycystic ovary syndrome9 Purposes
and pitfalls" Obstetrical" 0--=G*7(0)9,=,+,*="
Cheun AP" (ltrasound and menstrual history in predictin endometrial hyperplasia in
polycystic ovary syndrome" Obstet 5ynecol" 0--,G7C(0)980*+88,"
)hrmann DA" Polycystic ovary syndrome" ; )nl I Med" 0--*G8*0(,0)9,008+,08B"
5u:ic1 DS" Polycystic ovary syndrome" Obstet 5ynecol" 0--=G,-8(,)9,C,+,78"
Orchard TI# et al" The effect of metformin and intensive lifestyle intervention on the
metabolic syndrome9 The Diabetes Prevention Proram randomi:ed trial" Ann $ntern
Med" 0--*G,=0(C)9B,,+B,7"
&evised 0--8 consensus on dianostic criteria and lon%term health ris1s related to
polycystic ovary syndrome (PCOS)" 6um &eprod" 0--=G,7(,)9=,+=/"
(rbane1 M# et al" Candidate ene reion for polycystic ovary syndrome on
chromosome ,7p,8"0" I Clin )ndocrinol Metab" 0--*G7-(,0)9BB08+BB07"
Miscellaneous
Synonym(s)
J Syndrome KK
J Stein%2eventhal syndrome
Clinical Pearls
J Sins and symptoms of PCOS may bein in adolescence" Severely irreular menses
!ith moderate to severe acne and4or hirsutism should not be dismissed as Lnormal
adolescence"M
J Coordination of care bet!een primary care# dermatoloy# endocrinoloy# and
ynecoloy is essential"
Abbreviations
J CA6NConenital adrenal hyperplasia
J DBPNDiastolic blood pressure
J D6)ASNDehydroepiandrosterone sulfate
J DMNDiabetes mellitus
J DT&NDeep tendon refle<es
J 'S6N'ollicle%stimulatin hormone
J 5n&6N5onadotropin%releasin hormone
J 5TTN5lucose tolerance test
J 6T;N6ypertension
J $'5N$mpaired fastin lucose
J $5TN$mpaired lucose tolerance
J $>'N$n vitro fertili:ation
J 26N2uteini:in hormone
J OCPNOral contraceptive pills
J SBPNSystolic blood pressure
J S6B5NSe< hormone bindin lobulin
J T=NThyro<ine
J TS6NThyroid%stimulatin hormone
J (S )CN(ltrasound endometrial comple<
J 3CN3aist circumference
Codes
$CD7%CM
B0C"-# 0*B"= Polycystic ovarian syndrome
Patient Teachin
J 2ifestyle modification is 1ey
J 'ocus on chronic disease manaement and prevention of cardiovascular ris1s
J http944!!!"asrm"or4Patients4'actSheets4PCOS"pdf
J http944=!omen"ov4faE4pcos"htm
J http944!!!"aco"or4publications4patientOeducation4bp,0,"cfm