POLYCYSTIC OVARY
SYNDROME (PCOS)
Presenter: Hamizah
Supervisor: Dr Mushaqiril
Specialist: Dr Izza
Contents
1. Clinical scenario
2. Definition
3. Pathogenesis
4. Clinical features
5. Diagnosis
6. Treatment
Clinical scenario
• Miss J is a 25 years old woman,
married, nulliparous, who was referred
to the Obs and gynae department by
her family doctor after complaining of
not having a period for the last six
months. She also has been trying to
conceive for the last year and a half
without success. She has noticed a
significant weight gain (25 kg) over the
last few months and was convinced
she was pregnant even though all tests
have come back negative.
• Gynaecology history:
• menarche at age 15 years old
• History of amenorrhea and abnormal vaginal bleeding. Bleeding
duration between two and 15 days.
• Cycle range monthly to every three months.
• Past medical history:
• Acne, age 20 to present, sees dermatologist
• Laser hair removal on face, age 25
• Psychotherapy, age 24 to present, for anxiety and sleep disturbance
• Family history:
• Mother alive at age 50 years, history HTN, Type 2 Diabetes,
and obesity, and infertility, treatments with second
pregnancy
• Father alive and healthy at 52 years
• Sister alive at age 20 years, history obesity and Type 2
diabetes
• Sister had PCOS
• Social history:
• Has worked full-time as staff nurse for last 2 years
• Hobbies include cooking, baking, and reading
• Married for two years
Differential diagnoses
1. Hypothyroidism
2. Cushing’s syndrome
3. Hyperprolactinemia
PCOS
• Is a condition that can affect periods,
fertility, hormones and aspects of an
appearance in a woman.
• It can also affect one’s long-term
health
• Polycystic ovaries are slightly larger
than normal ovaries and have twice
the number of follicles (fluid-filled
spaces within the ovary that release
the eggs when ovulation happen)
High risk groups
• Oligo-ovulatory infertility
• Obesity and/or insulin resistance
• A history of premature adrenarche
• First degree relative with PCOS
• Use of anti-seizure medications (valproic acid)
Pathogenesis
GENETICS
• Complex genetics trait (multiple genetic variants and
environmental factors interact for the development of
the disorder)
• The prevalence of PCOS in mothers and sisters of
PCOS women is 20 – 40 %, considerably higher than
that seen in general population.
Gonadotropin secretion and action
• PCOS patients often have higher serum LH
concentrations, enhances hypersecretion of
androgens in the theca cells in ovarian follicles
• The increase in follicular androgens impairs follicular
development and reduces normal inhibition of GnRH
pulse frequency by progesterone, further promoting
development of PCOS
Dysfunction in ovarian folliculogenesis
• In PCOS, the selection of a dominant follicles is
abnormal, as a result of insufficient FSH stimulation
and local inhibition of FSH action
Insulin secretion and action
• PCOS patients frequently have insulin resistance, and
development of compensatory hyperinsulinemia
• Insulin stimulates theca cell secretion of androgens,
resulting in increase in free androgens
Weight and energy regulation
• The presence of obesity worsens insulin resistance,
the degree of hyperinsulinemia, the severity of
ovulatory and menstrual dysfunction, and pregnancy
outcome in PCOS
• Also, associated with an increasing prevalence of
metabolic syndrome, glucose intolerance,
cardiovascular risk factors, and sleep apnea
Androgen biosynthesis and action
• Hyperandrogenism is a central feature for most forms
(phenotypes) of PCOS.
• The androgens are secreted primarily by the ovaries
and secondarily by the adrenals
Environmental factors
• The development of PCOS are affected by
environmental factor such as diet and obesity
Clinical features
• Obesity
• Oligomenorrhea
• Hyperandrogenism
• Glucose intolerance
• Dyslipidemia
• Fatty liver
• Obstructive sleep apnea
Menstrual dysfunction
• Menstrual pattern include oligomenorrhea (fewer than
nine menstrual periods in a year) and less often,
amenorrhea (no menstrual periods for three or more
consecutive months)
• Women with PCOS often experience more regular
cycles after age 40 years old
Hyperandrogenism
• Hirsutism
• Acne
• Male-pattern hair loss
• Virilization (sign of more severe androgen excess),
such as deepening of the voice and clitoromegaly
Metabolic
Polycystic ovaries issues/cardiovascular risks
• Can be seen on transvaginal • Approximately 40 to 85
ultrasound percent of women with PCOS
are overweight or obese
• Non-alcoholic steatohepatits
• Sleep apnea
• Mood- PCOS is associated with mood disorders
(depression and anxiety), impaired quality of life, and
eating disorders (binge eating)
Diagnosis
Rotterdam criteria
• Two out of three of the following criteria are required
to make the diagnosis:
• Oligo- and/or anovulation
• Clinical and/or biochemical signs of hyperandrogenism
• Polycystic ovaries (by ultrasound)
Differential diagnoses
However, other conditions that mimic PCOS must be
excluded
• thyroid disease
• non classic congenital adrenal hyperplasia
• Hyperprolactinemia
• androgen-secreting tumors
Further evaluation after diagnosis
• Cardiometabolic risk assessment
• Screening for mood disorder
• Non-alcoholic fatty liver disease
• Obstructive sleep apnea
• Assessment of ovulatory status (for woman pursuing
fertility)
Treatment Goals
• Hyperandrogenic features improving (hirsutism, acne, scalp hair
loss)
• Reduction of risk factors for type ii diabetes mellitus and
cardiovascular disease
• Prevention of endometrial hyperplasia and carcinoma, which may
occur as a result of chronic anovulation
• Contraception, as women with oligomenorrhea ovulate intermittently
and unwanted pregnancy may occur
• Ovulation induction for those which to pregnant
Women not pursuing pregnancy
• Combined estrogen-progestin oral contraceptives (COC)
as first-line therapy for menstrual dysfunction and
endometrial protection
• Benefits:
• daily exposure to progestin, which antagonize the
endometrial proliferative effect of estrogen
• Contraception in those not pursuing pregnancy
• Cutaneous benefits for hyperandrogenic manifestations
• Alternative to COC (for endometrial protection), are
progestin therapy, or a progestin-releasing
intrauterine device (IUD)
• COC as first line treatment for most women with
hirsutism. An anti-androgen is then added after six
months if the cosmetic response is suboptimal
(finasteride, cyproterone acetate, and flutamide
(hepatotoxicity)
• For women with hirsutism and contraindications to COC,
spironolactone can be used as an anti-androgen
(however, other form of contraception still needed)
• Weight loss, which can restore ovulatory cycles,
improve metabolic risk, and possibly improve live
birth rates
• Type ii diabetes mellitus should be treated
Women pursuing pregnancy
• Ovulation induction medications: letrozole and
clomiphene citrate
• Other medications include, metformin, which had
been used in combination with clomiphene (in PCOS
with type ii diabetes)
• Exogenous gonadotropin also can be used to induce
ovulation
• Other approach such as laparoscopic surgery, called
ovarian drilling can be used.
• When compared with gonadotropin therapy, another
second-line treatment, ovarian drilling has similar
efficacy but results in lower risk of high order multiple
gestations or OHSS
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