Topic
Polycystic ovary syndrome
(PCOS)
Extern Thanatchaporn Puangnak
Rotate D1 61460414
Definition
■ Polycystic ovary syndrome (PCOS) is the most common
endocrinopathy affecting reproductive-aged women, with impacts
across the lifespan from adolescence to post menopause
■ PCOS is believed to be a multifactorial disorder of both genetic and
environmental factors
Pathophysiology
■ Unknown cause
■ Multifactorial and polygenic
■ Genetic basis suspected
- Androgen synthesis : CYP11A gene, CYP17A gene
- Insulin resistance : insulin receptor gene on chromosome 19p13.2
■ Predisposing factors
- Family history of PCOS
- High maternal androgen
- Onset DM type I before menarche
- Insulin resistance
- Obesity
Pathophysiology
Sign and symptoms
■ Menstrual dysfunction
- Amenorrhea
- Oligomenorrhea
- Menometrorrhagia
■ Hyperandrogenism
- Hirsutism: terminal hairs, male pattern, Acne
- Androgenic alopecia
■ Insulin resistance
- Acanthosis nigricans
- Common in obesity patient
■ Infertility
- Anovulation,
- Abortion,
- GDM, PIH
Hyperandrogenism: Hirsutism
Ludwig or Olsen
visual scales
Insulin resistance - Acanthosis nigrican
Diagnosis
Diagnosis: ESHRE 2023
Diagnosis
Diagnosis
Biochemical
hyperandrogenism
Diagnosis Ultrasound
■ Follicle number per ovary (FNPO) ≥ 20 in at least one ovary
■ Follicle number per cross-section (FNPS) ≥ 10 in at least one ovary
■ Ovarian volume (OV) ≥ 10 mL at least one ovary
■ TVS more accurate than TAS
■ TAS same criteria as TVS but in either ovary
Diagnosis Ultrasound
■ Polycystic ovary
■ ≥ 10 small follicles, placed
peripherally, each follicle size
2-9 mm → string of pearls
■ Ovarian enlargement
■ Rules out ovarian tumor
Differential
diagnosis
Consequences of
PCOS
Consequences of PCOS: Investigation
■ Obesity: BMI, waist circumference
■ Hypertension: BP
■ Insulin resistance: 75 g OGTT, FBS
■ Indication:
- Age> 40 yr
- BMI >31 kg/m2
- Acanthosis nigricans,
- Hx GDM
- Family history of Type 2 DM
■ Dyslipidemia: Lipid profile
■ Mood disorder
■ Other: Fatty liver, Sleep apnea
Cardiovascular risk
Long term assessment for PCOS patient
■ Waist circumference and BMI : every visit
■ Blood pressure: every visit
■ Lipid profile: If normal, assess every 2 years or sooner if weight gain
■ 75 g OGTT: If normal, assess every 2 years or sooner if additional risk
factors present
Management
Lifestyle modification
■ Weight management reduce 5-10%, waist circumference<80cm
■ Diet control: reduce 500-1000 kcal/day
■ Exercise:
- Moderate intensity, 150-300 minutes/weeks
- Vigorous intensity, 75-150 minutes/weeks
Combined oral contraceptives
■ COCP is recommended in reproductive age adults for
management of hirsutism and/or irregular menstrual cycles
■ Reduced Hyperandrogenism
■ Reduced risk of endometrial hyperplasia
■ Progestin with low androgenic activity
- Norethindrone
- Norgestimate
- Desogestrel
- Drospirenone
- Cyproterone acetate
Cyclic progestins
■ 10-14 days/month
■ Medroxyprogesterone acetate (MPA) 5-10 mg/day
■ Micronized progesterone 200 mg/day
Insulin sensitizing agents (Metformin)
■ Reduced Insulin resistance:
- Reduced hepatic glucose production,
- increased Insulin sensitivity
- Reduced Androgen
■ Start low dose (500 mg/day) → 1,500-2,000 mg/day
■ ADR:
- GI symptom (nausea, vomiting, diarrhea)
- Lactic acidosis
■ Use in BMI ≥ 25 kg/m
COCP vs Metformin
■ COCP > metformin : hirsutism in irregular menstrual cycles
■ Metformin > COCP for metabolic indications of PCOS
■ Indication of combination therapy:
- High metabolic risk groups (BMI > 30kg/m2)
- Diabetes risk factors,
- Impaired glucose tolerance or high-risk ethnic groups
Treatment hirsutism: Medication
■ Combined oral contraceptives
■ Eflornithine hydrochloride (irreversible inhibitor of ornithine
decarboxylase)
■ Androgen-receptor antagonist
- Spironolactone 25-100 mg/day
- Cyproterone acetate 50-100 mg/day
- Flutamide 125-250 mg/day
■ 5α-reductase inhibitors : Finasteride รับประทาน 2.5-5 mg/day
Treatment hirsutism: Cosmetic
■ Depilation (Hair removal above skin surface)
- shaving, topical chemical depilatory agent
■ Epilation (Remove the entire hair shaft and root)
- plucking, waxing, threading, electrolysis, laser
■ Bleaching
Treatment Acne
■ Combined oral contraceptives (COC)
■ Antiandrogens
- Spironolactone
- Flutamide
■ 5α-reductase inhibitors
- Finasteride
Treatment
infertility
References