Polycystic Ovarian Syndrome

Polycystic
Ovarian
Syndrome
DEFINITION
• PCOS is a common disorder, often complicated by chronic anovulatory
infertility and hyperandrogenism with the clinical manifestations of
oligomenorrhoea, hirsutism and acne.
Epidemiology
• Most common endocrine disorder in women.
• Affecting 5-10% of women in reproductive age.
Pathophysiology
• Aetiology : Unknown.May have multiple mechanism causing disruption of
the ovarian pituitary feedback mechanism .
• Possible mechanisms include:
- Intrinsic ovarian problems (excess ovarian production of androgen)
- Intrinsic adrenal problem (excess adrenal production of androgen)
- Hypothalamic pituitary dysfunction (inappropriate GnRH release causing
elevated LH but not FSH
- Metabolic , with the aetiologic factor being insulin resistance
(hyperinsulinemia)
• Has familial predisposition
pathophysiology
Long Term Consequences
• Macrovascular diseases : DM, HTN, and artherosclerotic heart
disease.
• Chronic anovulation- high risk of endometrial hyperplasia and uterine
carcinoma production
• Higher first trimester miscarriage and gestational diabetes if pregnant.
• Infertility secondary to chronic anovulation.
Clinical History
• Menses which can be irregular or scanty (oligo or
amenorrhea), heavy or prolonged.
• History of androgen excess ( hirsutism, acne , alopecia)
• Infertility with anovulation(40%)
• Family history of PCOS, DM
Physical examination
• Features of hyperandrogenism and need
to exclude virilisation.
• Assessment of obesity –BMI , waist-hip
ratio. High BMI present in up to 65% of
women with PCOS
• Acanthosis nigricans
Diagnosis
• Rotterdam criteria
• 1. polycystic ovaries (either 12 or more follicles or
increased ovarian volume [> 10 cm3 ])
• 2. oligo-ovulation or anovulation
• 3. clinical and/or biochemical signs of hyperandrogenism.
• It should be noted that the diagnosis of PCOS can only be

made when other aetiologies for irregular cycles, such as
thyroid dysfunction, acromegaly or hyperprolactinaemia,
have been excluded if there is clinical suspicion.
Investigations
• Ultrasound scan of pelvis
-transvaginal US is the best method to assess the endometrial thickness and the ovaries
• UPT
• Endometrial biopsy ( if has abnormal uterine bleeding or thickened endometrium by US)
• Serum androgen
-testosterone ( free testosterone level)
-serum DHEAS( dehydroepiandrosterone sulfate) if serum testosterone > 5nmol/l
• FSH/LH –may have low or normal FSH and elevated LH
• Prolactin
• Others –TFT, 17 hydroxyprogesterone ( exclude CAH)
Diagnosis (rcog)
• Raised LH/FSH ratio is no longer a diagnostic criteria
• Recommended baseline screening tests
• TFTs
• Serum prolactin
• Free androgen index (total testosterone divided by SHBG x
100)
• Note; if testosterone >5 nmol/l exlude androgen-secreting
tumours
• Consider 17-hydroxyprogesterone
• Test for Cushing syndrome if clinical suspicion
Management
• Non pharmaceuticals
1. Weight reduction program
- 10 to 15% reduction can result in spontaneous ovulation and
conception more than 75% of women with PCOS.
2.Regular physical activity and dietary modification
• Medical
1. Fertility- ovulation induction using clomiphene citrate and/or FSH
-If clomiphene citrate resistance occurs, FSH administration is usually
successful but has higher rate of multiple pregnancy. The other
alternatives are : add metformin and restart clmiphene again or
proceed to laparoscopic ovarian drilling.
• . Menstrual regulation
• a.COC :
• -increases SHBG level, causing a fall in free testosterone level.
• -regulates menstrual cycle and prevents endometrial hyperplasia
• b.Progestogen :
• - for those whose main problem is oligo or 2ry amenorrhea
• -to induce a withdrawal bleed at least every 3-4months in order to
prevent endometrial hyperplasia and carcinoma
• Insulin sensitizing therapy –with Metformin
-reduction in serum levels of bioavailable androgens , LH and
atherogenic lipid.
It is able to restore menstrual cyclicity and induce ovulation by itself or
in combination with clmiphene in those who are previously not
responding to clomiphene alone.
-Weight-reduction drug may be helpful in reducing insulin-resistance
through weight loss
• Surgical (laparoscopic ovarian drilling)
-selected cases of anovulatory fertility with
normal BMI (clomiphene resistance and
those with high LH )as an alternative to
ovulatory induction
-Persistence of ovulation & normalisation of
serum androgens
-May affect reproductive capacity of ovaries
Advice for hirsutism & acne
• Impact on women’s self-image &
psychological effects
• Licensed treatments for hirsutism include
COCP, cosmic measures (laser,
electrolysis, bleaching, waxing, shaving)
and topical facial eflornithine (Vaniqa)
• Non-licensed treatments
• Spironolactone, antiandrogens
(flutamide, finasteride, high dose
cyproterone acetate), metformin
REFERENCE
• https://www.rcog.org.uk/globalassets/documents/guidelines/
gtg_33.pdf
• Quick Management Guide in Gynecology/Lee Say Fatt(2012),
published by University of Malaya Press.
• Jaypee 2nd Edition Essential of Gynecology by Shirish S Sheth

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• It should be noted that the diagnosis of PCOS can only be

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