PCOS:
PolyCystic Ovary Syndrome
By Kimberly Dovin, PGY3
Swedish Family Medicine
January 13, 2003
or
PCOS:
A Disorder for the Generalist
PCOS: Goals
• Identify patients with risks for or with Dx of
PCOS
• Assess patients appropriately for PCOS and
associated disease states
• Prescribe therapy to treat complaints and
prevent sequelae
PCOS: Objectives
• Define PCOS
• Understand pathophysiology
• Form an appropriate differential diagnosis
• Establish the work-up for PCOS
• Develop an array of therapies to treat
complaints and prevent bad outcomes
PCOS: Defined? I
• ACOG and NIH (1990): hyperandrogenism
and chronic anovulation excluding other
causes
• Stein and Levanthal (1935): association of
amenorrhea with polycystic ovaries and
variably: hirsutism and/or obesity
PCOS: Epidemiology
• Prevalence: 4-6% females
– Probably same world wide
• No difference between blacks and whites
• 75% of women w/ irregularity or infertility
PCOS: Signs and Symptoms
SYMPTOMS SIGNS
• Menstrual • Hirsutism, acne
irregularity • Obesity
• Infertility • Ovarian enlargement
• Hirsutism, acne, etc • Acanthosis nigricans
• Obesity
PCOS: Signs and Symptoms II
PCOS: Imaging and Pathology
PCOS: Pathopysiology
What we think we know.
• “Vicious cycle”
• Abnormal gonadotropin secretion
– Excess LH and low, tonic FSH
• Hypersecretion of androgens
– Disrupts follicle maturation
– Substrate for peripheral aromatization
• Negative feedback on pituitary
– Decreased FSH secreation
• Insulin resistance, Elevated insulin levels
PCOS: Current theories of
pathopysiology
Downstream Autosomal
Signal Defect Dominant Gene GnRH E2
LH
Insulin PCOS A
Resistance
A=androgens, E2=estradiol
“Could the theory of chaos
contribute to the interpretation
of pathogenesis of polycystic
ovary syndrome?”
PCOS: Case 1 - Hx
• J.D. 31yof
• Menstrual irregularity,LMP 5 months prior
– Irregular since menarche
– Getting longer over time
• Sexually active and uses condoms
• 40lb weight gain over past six months
• Previous U/S w/ ovarian cysts
• ROS: hair growth on her chin and chest
• Meds: HCTZ, Effexor, atenolol
PCOS: Case 1 - PE
• BP 126/96, Weight 248lbs
• Skin: dark hair on chin and chest, moderate to
severe acne on face and back
– no acanthosis nigricans
• Abd-obese, tender RLQ, no R/G, no abd striae
• Pelvic exam – nl ext genitalia no clitoromegaly,
norm appearing cervix
• Bimanual: Uterus/adnexa not palpated
• U/S: Normal appearing ovaries
PCOS: Differential Dx
• Androgen secreting tumor
• Exogenous androgens
• Cushing’s syndrome
• Nonclassical congenital adrenal hyperplasia
• Acromegaly
• Genetic defect in insulin metabolism
• Primary hypothalamic amenorrhea
• Primary ovarian failure
• Thyroid dz
• Prolactin dz
PCOS: Case 1 Work-up
• Total or free testosterone
• +/- LH and FSH
• Pelvic U/S
• Fasting glucose
• Fasting lipid profile
• (SHBG, Insulin)
PCOS: Work-up (cont’d)
• TSH
• Prolactin
• UHCG
• +/- 17-hydroxyprogesterone
• +/- Dexamethasone suppression test
• +/- DHEA
PCOS: Case 1 Treatment
• Oligomennorhea
– OCPs, Progestins, insulin-sensitizing agents
• Hirsutism
– OCPs, Antiandrogens, ISAs, Eflornithine
– Mechanical treatments
• Obesity
– LIFESTYLE MODIFICATIONS
– Metformin
PCOS: Case 1 Treatment
• Naturopathic options
– Flaxseed oil
– Fish oil
– D-chiro-inositol
– Chromimum
– Urtica Dioica (aka stinging nettle)
– Saw palmetto
Case 1: Outcomes
• Laboratory analysis: Nl TSH and prolactin,
mild elevation of testosterone, LH:FSH 3:1
• Treatment: Diet and exercise counseling,
metformin 850mg bid.
• Patient reported resumption of menses and
thereafter lost to f/u
PCOS: Case 2 - Hx
• R.M. 27yof
• Desires pregnancy w/o results X 2yrs
• LMP 2 wks ago/ 3 menses per yr
– 2 years irregularity,
– sometimes heavy bleeding
• Simlar family hx
• C/o facial hair which she waxes
• No infertility w/u
PCOS: Case 2 – P.E.
• Weight 247 lbs
• Skin: Scant facial hair on chin, no acne
• Abd: obese
• Pelvic: norm uterus, ovaries not palpated
• Labs: mild elev prolactin & testosterone,
elevated LH
• Pelvic US WNL
PCOS: Infertility
• WEIGHT LOSS
• Clomiphene citrate 50-100mg QD +/-
dexamethasone
• Gonadotropins
• Metformin
• Ovarian Drilling
PCOS: Risks of Pregnancy
• Gestational Diabetes?
• Hypertension?
PCOS: Case 2 - Outcomes
• Metformin 500mg bid
– Menses resumed q28 d X 2
• Anxious to get pregnant.
– Advised following BBTemps
– Timing intercourse.
– If no result in 3mos start Clomid.
PCOS: Case 3 - Hx
• M.P. 39yof
• F/u acne face and back
• C/o hirsutism, “like a beard”
• Oligomennorhea, q60day cycles
• G2P2 s/p BTL 14 years ago
• ROS: weight gain 50lbs in 3-4 years
PCOS: Case 3 - P.E.
• BP 146/92
• Weight 232lbs, BMI 36.3
• Skin: Severe acne on face and back,
evidence of shaving on face
PCOS: Associated Disorders
• Diabetes
• Hyperlidpidemia (LDL, Triglycerides)
• Obesity
• Hypertension
• CAD?
– Incr in Risk Factors, but not mortality
PCOS: Associated Disorders
• Endometrial CA
• Ovarian CA?
• +/- Breast CA
• NO increase in Osteoporosis
• Eating disorders
• Psychiatric dz
PCOS: Case 3 Follow-up
• TSH, Prolactin, Free Testosterone, 17-OH
progesterone all WNL
• Fasting glu = 99 LDL = 125
• Referred to nutrition and prescribed
exercise program
– Pt lost 30lbs over one year, menses more
regular, hirsutism and acne slightly improved
– LDL dropped to 110, BP normalized
PCOS: Conclusion
• PCOS: chronic
anovulation/hyperandrogenism
• Complete a w/u to r/o other causes
• Advise weight loss and exercise in all
patients w/ PCOS
• Consider medical management
• Use a Palm memo
Bibliography
• Plycystic Ovary Syndrome. Clinical Management Guidelines. Dec
2002; ACOG Practice Bulletin No. 41.
• Hunter, H., MD and Sterrett, J, PharmD. Polycystic Ovary Syndrome:
It’s Not Just Infertility. AFP. Sept. 1, 2000.
• Keri Marshall, ND Candidate 2001 Polycystic Ovary Syndrome:
Clinical Considerations.
• Macut D, et al. Cardiovascular risk in adolescent and young adult
obese females with polycystic ovary syndrome (PCOS). J Pediatr
Endocrinol Metab. 2001;14 Suppl 5:1353-59; discussion 1365.
• Poretsky, Insulin Resistance and the Polycystic Ovary Syndrome:
Mechanism and Implications for Pathogenesis; Endocrine Reviews 20
(4): 535-582.