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Polycystic Ovarian Syndrome

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Polycystic Ovarian Syndrome

  1. 1. Irregular Bleeding Amit Abraham Primary Care Clerkship
  2. 2. • J.D. 22 yo f • Menstrual irregularity, LMP 5 months prior – Irregular since menarche • Sexually inactive • 18kg weight gain over past six months • ROS: hair growth on her chin and chest
  3. 3. • PCOS is a complex endocrine disorder affecting women of childbearing age characterized by increased androgen production and ovulatory dysfunction • Prevalence 6-8% of normal population
  4. 4. Diagnostic Criteria • Rotterdam Criteria (2 out of 3) – Menstrual irregularity due to anovulation or oligo-ovulation – Polycystic ovaries (by ultrasound) – Evidence of clinical or biochemical hyperandrogenism • Clinical: hirsutism, acne, or male pattern balding • Biochemical: high serum androgen concentrations
  5. 5. Menstrual Irregularity • Begins in the peripubertal period • Menarche may be delayed • Oligomenorrhea (fewer than nine menstrual periods in a year) • Amenorrhea (no menstrual periods for three or more consecutive months)
  6. 6. Hyperandrogenism • Hirsuitism • Acne • Male pattern hair loss
  7. 7. Hyperandrogenism
  8. 8. • Signs of more severe androgen excess occur only rarely • these signs should prompt the search for androgen-producing neoplasms. • deepening of the voice • clitoromegaly • increased muscle mass
  9. 9. Hirsuitism • excessive hair that appears in a male pattern • commonly graded according to the Ferriman-Gallwey system • Normal < 8 • Mild Hirsuitism: 8-15 • Moderate to severe Hirsuitism >15
  10. 10. U/S • Transvaginal U/S is preferred • Normal: – scattered follicles – volume<8cm3 • Polycystic: – 12 or more follicles > 2-9mm in diameter – Volume>10cm3 due to increased ovarian stroma
  11. 11. Obesity • Present in 45% of PCOS • Often is initial complaint • 2/3 of patients with PCOS who are not obese have excessive body fat and central adiposity
  12. 12. Hyperinsulinemia and IGT • Approximately 10 percent of women with PCOS will have type 2 diabetes mellitus (DM) by 40 years of age, and about one-third will have an abnormal glucose tolerance test • Hyperinsulinemia contributes to hyperandrogenism its suppressive effects on sex hormone binding globulin production by the liver and enhancing LH secretion
  13. 13. Acanthosis Nigricans • Velvety plaques on nape of neck and intertriginous areas • Epidermal hyperkeratosis • Associated with insulin resistance
  14. 14. Dyslipidemia • serum HDL • high serum triglycerides • high serum LDL
  15. 15. Androgens • Free testosterone is the most sensitive test to establish the presence of hyperandrogenemia • LH:FSH > 3:1 • DHEAS and 17-hydroxyprogesterone
  16. 16. DDx 1. Congenital Adrenal Hyperplasia • autosomal recessive deficiency in the activity of any one of the adrenocortical enzyme steps necessary for the biosynthesis of corticosteroid hormones in the adrenal gland. • morning serum 17-hydroxyprogesterone concentration greater than 200 ng/dL in the early follicular phase strongly suggests the diagnosis • confirmed by a high dose (250 mcg) ACTH stimulation test: post-ACTH serum 17- hydroxyprogesterone value less than 1000 ng/dL
  17. 17. DDx 2. Ovarian and adrenal tumors • serum testosterone concentrations are always higher than 150 ng/dL • adrenal tumors: serum DHEA-S concentrations higher than 800 mcg/dL • Low serum LH concentrations
  18. 18. DDx 3. Cushing Syndrome 4. Hyperprolactinemia 5. Acromegaly 6. Thyroid dysfunction
  19. 19. • The chronic anovulation seen in PCOS is associated with an increased risk of endometrial hyperplasia, dysfunctional uterine bleeding, and possibly endometrial cancer
  20. 20. Therapy • Hyperandrogenism • Menstrual Irregularity and Infertility • Metabolic syndrome
  21. 21. Hyperandrogenism • Combination OCP is first-line pharmacologic therapy for most women • Antiandrogen is then added after six months if the cosmetic response is suboptimal (spironolactone or flutamide )
  22. 22. OCPs • Suppress ovarian androgen • Increase SHBG • Regular menstrual cyclicity • Progestin opposition • Endometrial protection
  23. 23. Infertility • Weight loss! • Reduction in serum testosterone concentration and resumption of ovulation
  24. 24. Infertility • Clomiphene citrate • Metformin • Risk of multiple pregnancy
  25. 25. Metabolic Syndrome • As anyone with metabolic syndrome • Lifestyle Modification • Strict glucose control • Antihypertensives • Statins
  26. 26. References • Uptodate.com • Azziz R et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertility and Sterility:91(2) February 2009; 456-488 • Eagleson et al. Polycystic ovarian syndrome: evidence that flutamide restores sensitivity of the gonadotropin-releasing hormone pulse generator to inhibition by estradiol and progesterone. J Clin Endocrinol Metab 2000 Nov;85(11):4047-52 • Plycystic Ovary Syndrome. Clinical Management Guidelines. Dec 2002; ACOG Practice Bulletin No. 41 • Poretsky, Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis; Endocrine Reviews 20 (4): 535-582.

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