Clinical Features
1. Initiated either in inutero or in early adolescent life
2. Early adrenarche – in the form of early pubertal hair amd early menarche
3. Menstrual changes
Initial few years – normal
Progresses to oligomenorrhoea as clinical features develops (87%) or Amenorrhea (26%)
Followed by prolonged or heavy periods
Dysmenorrhoea is absent
4. Reproductive years
Infertility due to anovulatory cycles
Abortion in 20-30%
Carbohydrate intolerance, diabetes or hypertension will be developed if she conceives
5. Hyperandrogenism
Acne
Hirsutism – facial hair over upper lips, chin , breast, and thighs
Virulism is not seen
Examination of a girl
with PCOS
History
• Lifestyle
• Diet
• Smoking
• Exogenous hormone administration
• Family history of diabetes and hypertension
Examination
• Obesity – waist to hip ratio >0.85 is abnormal
• BMI- 23-24.9 is overweight, >25 obese
• Thyroid enlargement
• Hirsutism, Acne
• Hyperinsulinemia – manifests as acanthosis nigricans ( nape of neck,
axilla, below the breasts
• Blood Pressure
• Pelvic findings are usually normal
• Avoid PV in Unmarried women
Diagnostic criteria –
Rotterdam Criteria
(2003)
Adrenal hyperplasia
Differenti
al Cushing's Disease
Diagnosi
s Ovarian Male hormone
producing tumors
INVESTIGATIONS
Ultrasound
• Enlarged ovaries
• Ovarian volume >10mm3
• 12 or more follicles each of 2-9mm in size, peripherally placed in the
subcapsular region
• Endometrial hyperplasia
• Increased blood flow
Performed in the early follicular phase
To monitor response of medication
These changes cannot be relied on a woman taking OCPs
Hormonal studies
• Not done routinely
• In adrenal tumor/ hyperplasia - abdominal scan, DHEA-S, 17 – OH
hydroxy progesterone help in the diagnosis
• Thyroid function tests
• Laparoscopy – enlarged bilateral ovarian cysts
TREATMENT
Lifestyle Changes
• Weight loss
• Cigarette smoking must be stopped
• Diet- Increase fiber content
• Exercise
Oral Contraceptive Pills
• Estrogen suppresses androgens and adrenal hormones (DHEA)
• Raises SHBG levels in the liver – binds with free testosterone
• Suppresses LH
• Best given as low dose combined pills, congaing progesterone with
lesser androgenic effect
4th Generation Combined Pills
• Contains 30mcg estradiol + 3mg drospirenone
• Reduces Acne
• Prevents water retention and reduced weight
• Maintains lipid profile
Progestogen
• Induces menstruation in an amenorrhoeic woman prior to initiation
of hormonal therapy
Hirsutism
• OCPs containing cyproterone acetate or spironolactone is given
Acne
• Clindamycin lotion 1% or erythromycin gel 2% (pustules)
• Severe acne – isotretinoin (teratogenic )
Infertility
• Clomiphene
• Dexamethasone – if levels of DHEAS are raised- 0.5mg (0-0-1)
• Tamoxifen/ Letrozole is clomiphene resistance develops
• GnRH analogues, gonadotropins – are used as a last resort
• N Acetyl Cysteine + clomiphene – if homocysteine levels are elevated
Metformin
• Reduces production and absorption of glucose , improves peripheral
utilization of glucose
• Increases SHBG
• Contraindicated in hepatic renal disease, Acarbose can be used
• Starting dose 500mg OD, gradually increased to 500mg TID
• Not to be given for >6 months
• NAC + micronutrients ( vitamin D, minerals, chromium, Selenium,
Inositol, folic acid )- are preferred over metformin by some
Surgery
Indications –
• Medical therapy fails
• Hyperstimulation of ovaries
• Infertile Women
• Previous pregnancy loss
Laproscopic drilling or puncture of of not more than 4 cysts ( laser or
electro c