Polycystic ovarian syndrome

• PCOS is the most common endocrine disorder in

women.
• Responsible for 80% of all cases of anovulatory
subfertility.
• Estimated prevalence is 6–10% of women of
childbearing age.
• USS evidence of polycystic ovaries is seen in 20–
30% of women
 Rotterdam criteria for diagnosing PCOS

Requires the presence of two out of the following three

variables and exclusion of other disorders:
 Irregular or absent ovulation(cycle >42 days).
 Clinical or biochemical signs of hyperandrogenism:
• acne
• hirsutism
• alopecia.
 Polycystic ovaries on pelvic USS: ≥ 12 antral follicles on
one ovary.
• Ovarian volume >10mL.
 Aetiology

The pathogenesis of PCOS is not fully known. There is hypersecretion

of LH in ~60% of PCOS patients (LH stimulates androgen secretion from
ovarian thecal cells). Elevated LH:FSH ratio is often seen, but is not
needed for diagnosis. The following factors have been implicated:
 Genetic (familial clustering).
 Insulin resistance with compensatory hyperinsulinaemia (defect on
insulin receptor).
 Hyperandrogenism (elevated ovarian androgen secretion).
 Obesity:
• BMI >30 in 35–60% of women with PCOS
• central obesity
• worsens insulin resistance
 Investigation

 Basal (day 2–5): LH, FSH, TFTs, prolactin, and testosterone.

 If hyperandrogenisim:
• dehydroepiandrosterone sulphate (DHEAS)
• androstenedione
• SHBG.
 Exclude other causes of secondary amenorrhoea.
• Pelvic USS.
Examination
• BMI.
• Signs of endocrinopathy, hirsutism, acne, alopecia, acanthosis
nigricans
Long-term health consequences of PCOs

• Obesity, insulin resistance, and metabolic

abnormalities including dyslipidaemia are all risk
factors for ischaemic heart disease
• Type II diabetes is a known risk of obesity and
insulin resistance, and pregnant women with PCOS
are at increased risk of gestational diabetes
• Long periods of s amenorrhoea, with resultant
unopposed oestrogen, are a risk factor for
endometrial hyperplasia and, if untreated,
endometrial carcinoma.
 Polycystic ovarian syndrome:
management

• The options should focus on the main concern

of the woman.
• Lifestyle modification
• This is the cornerstone to managing PCOS in
overweight women. Even amodest weight loss
(5%) can improve symptoms.
 Improving menstrual regularity

• Weight loss.
• COCP.
• Metformin.
 Controlling symptoms of hyperandrogenism

1) Cosmetic (depilatory cream, electrolysis, shaving, plucking).

2) Antiandrogens such as eflornithine facial cream, finasteride, or
spironolactone:
• can be used to help with acne and hirsutism
• can take 6–9mths to improve hair growth
• avoid pregnancy (feminizes a male fetus).
3) COCP:
• reduces serum androgen levels by increasing SHBG levels
• co-cyprindiol combines ethinylestradiol and cyproterone acetate,
providing a regular monthly withdrawal bleed and beneficial
antiandrogenic effects
.
 Subfertility

• Weight loss alone may achieve spontaneous ovulation.

• Ovulation induction with antioestrogens or
gonadotrophins.
• Laparoscopic ovarian diathermy.
• IVF if ovulation cannot be achieved or does not succeed
in pregnancy.
 Women with PCOS who undergo IVF are at increased
risk of ovarian hyperstimulation syndrome
 • Insulin sensitizer
Metformin has been most widely used
• Metformin combined with ovulation induction
with clomifene citrate increased ovulation and
pregnancy rates
• Does not significantly improve hirsutism, acne,
or weight loss, despite lowering androgen levels
and improving insulin sensitivity.
 Psychological issues

• PCOS can be difficult to manage and patients

may require additional motivation.
• Symptoms can be distressing and result in low
self-esteem. It is therefore important to
manage patients sensitively