Polycystic Ovary Syndrome Flashcards
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What is PCOS?
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- PCOS was first described in 1935 by American gynecologists Irving Freiler Stein and Michael Leventhal
- Stein and Leventhal’s report titled “Amenorrhea associated with bilateral polycystic ovaries” described patients who showed features of polycystic ovaries, hyperandrogenism, and menstrual irregularities
- Polycystic Ovarian Syndrome (PCOS) also referred to as Stein-Leventhal syndrome is one of the most common endocrine disorders affecting women of reproductive age.
- It is a heterogeneous disease characterized by androgen excess (hyperandrogenism) and menstrual irregularities.
- Many women presenting with PCOS have obesity (defined as a body mass index ≥ 30 mg/m2) and insulin resistance, which is a reduced biological response to insulin.
-It is now recognized as a major risk factor for the development of type 2 diabetes mellitus.
•5 - 15% women affected depending on the diagnostic criteria used
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Diagnosis of PCOS
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- The diagnosis of PCOS begins with a thorough history and physical examination.
- Clinicians should focus on the patient’s menstrual history, any fluctuations in the patient’s weight, and other findings (e.g., hair in a male patter distribution, excessive acne).
- Patients should also be asked about factors related to common comorbidities of PCOS.
- The Endocrine Society advises clinicians to diagnose PCOS using the 2003 Rotterdam.
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Dagnosis of PCOS - Rotterdam Criteria
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- hypergonadism
- menstrual irregularity
- polycystic ovaries on ultrasound
2/3 needed!
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Other Diagnostic Guidlines
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•There are a number of other abnormalities associated with PCOS including overweight/obesity, hypertension and insulin resistance. However, these conditions/diseases are not included in the diagnostic guidelines.
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PCOS Pathophysiology
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- Genetic and environmental (lifestyle) factors
- Strong interplay between endocrine and metabolic factors
- Patients with PCOS typically have increased LSH relative to FSH
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Biochemical/Laboratory Criteria
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- Elevated serum levels of luteinizing hormone, testosterone and DHEA-S (dehydroepiandrosterone sulfate)
- PCOS patients will show either normal or low levels of folliclestimulating hormone
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Pelvic Ultrasound
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•12 follicles of a diameter ranging between 2 and 9 mm develop on one or both ovaries and/or the ovarian volume in at least one ovary exceeds 10 ml (10cm3)
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Cysts
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- A polycystic ovary shows many follicles of a diameter ranging between 2 and 9 mm. The follicles group mainly round the periphery of the ovary
- “Cysts” are antral follicles (secondary follicle) which have arrested in development
- Polycystic ovaries are present in 20-30% of women and are not essential for the diagnosis of PCOS. The “cysts” in polycystic ovaries are not true cysts, but rather antral follicles which have arrested in development.
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Hirsutism/Acne
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- Excess androgens may cause excess hair growth in a male pattern distribution and acne.
- Excess androgens may cause excess hair growth in a male pattern distribution
- Hirsutism: 70% of PCOS patients
- The Ferriman-Gallwey scale is used for hirsutism.
- A score of 1 to 4 is given for nine areas of the body.
- A total score less than 8 is considered normal, a score of 8 to 15 indicates mild hirsutism, and a score greater than 15 indicates moderate or severe hirsutism.
- A score of 0 indicates absence of terminal hair.
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Obesity
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- In adult women, a waist circumference greater than or equal to 88 cm (35 inches) defines abdominal obesity
- Overweight is defined as a body mass index (BMI) of 25.0 to less than 30.0 kg/m2 and obesity is defined as a BMI of 30.0 kg/m2 or greater
- Obesity is present in approximately 50% of patients with PCOS
- The obesity in women with PCOS is due to both an increase in visceral fat and subcutaneous fat.
- Obesity in women with PCOS is due to both an increase in visceral fat and subcutaneous fat
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Risk Factors for PCOS
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- Family history of PCOS
- Premature adrenarche
- Low birth weight
- Fetal androgen exposure
- Excess insulin
- Low grade inflammation
- Sedentary Lifestyle
- Diet
14
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Insulin Resistance
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- 70% of patients with PCOS exhibit metabolic abnormalities, including insulin resistance and hyperinsulinemia
- Insulin resistance occurs when tissues such as adipose tissue, liver and skeletal muscles do not respond to insulin. This results in a compensatory increase in the secretion of insulin by the pancreas, causing hyperinsulinemia.
- Insulin resistance and compensatory hyperinsulinemia are also risk factors for other metabolic diseases, including type 2 diabetes and atherosclerosis (PCOS patients typically exhibit dyslipidemia).
- Insulin resistance is a risk factor for many diseases, including PCOS, type 2 diabetes and metabolic syndrome
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17
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How do hyperinsulinemia and hyperandrogenism interplay together and contribute to PCOS?
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- Progesterone is the primary regulator of gonadotropin-releasing hormone (GnRH) pulse frequency.
- In PCOS patients, the GnRH pulse generator is resistant to the negative feedback effects of progesterone.
- This resistance to progesterone negative feedback is mediated by androgen excess.
- The high GnRH pulse frequencies favor production of LH and limit production of FSH, which increases androgen production.
- The resulting high levels of LH promotes androgen production and interferes with normal follicular development.
18
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How do hyperinsulinemia and hyperandrogenism interplay together and contribute to PCOS?
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- Insulin resistance is a feature of PCOS and is due to genetics, environment and obesity Insulin resistant patients compensate by secreting excess insulin from the pancreas (hyperinsulinemia).
- Hyperinsulinemia results in the suppression of the sex-hormone-binding globulin (SHBG) and insulin growth factor binding protein 1 (IGFBP1) from the liver.
- Increased insulin and IGF1 levels stimulate the secretion of androgens from the ovaries [and the adrenal glands], which results in hyperandrogenis.
- The androgens enter tissues to exert their actions.
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Once Diagnosis is confirmed…
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•Proceed with screening for type 2 diabetes mellitus, dyslipidemia, hypertension and psychiatric disorders:
- Perform fasting glucose, insulin and hemoglobin A1c (HbA1c)
- Perform 2 hour oral glucose tolerance test
- Perform fasting lipid panel
- Measure blood pressure
- Evaluate for depression
22
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Management of PCOS
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- The treatment options for the patient are individualized based on their desire for ovulation/pregnancy.
- To summarize, the management of PCOS includes the following:
- Treatment of infertility
- Menstrual regulation in women who do not desire pregnancy
- Treatment of associated symptoms of hyperandrogenism (hirsutism, acne)
- Lifestyle modifications (including exercise combined with proper nutrition) for treatment and prevention of the metabolic disturbances (i.e. obesity and insulin resistance)
23
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Treatment Options for Wmen Who Wish to Achieve Pregnancy
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- Women who wish to achieve pregnancy/ovulation induction –> Clomiphene
- Hirsutism/Acne —> Depilatory/ Electrolysis
- Obesity —> Lifestyle Modifications
- Insulin Resistance/Menstrual Irregularities —> Metformin (Glucophage)
24
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Clomiphene
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- Description: Ovulation induction agent, selective estrogen receptor modulator
- Manifestations treated: Infertility
- Main adverse effects: Multiple pregnancy or ovarian hyperstimulation, thromboembolism
25
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Treatment Options for Wmen Who Need Contraception
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- Women who need contraception —> combination oral contraceptive pills
- Hirsutism/Acne —> Depilatory/Electrolysis/ Spironolactone
- Obesity —> Lifestyle Changes
- Insulin Resistance/Menstrual Irregularities —> Metformin (Glucophage)
26
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Spironolactone
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- Description: Antiandrogenic (androgen antagonists)
- Manifestations treated: Hirsutism Acne
- Main adverse effects: Hyperkalemia, nausea
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Metformin (Glucophage)
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- Description: Insulin sensitizing agent
- Manifestations treated: Insulin resistance (first-line therapy) Menstrual irregularities (second-line therapy)
- Main adverse effects: Gastrointestinal upset
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