POLYCYSTIC OVARY SYNDROME

1. POLYCYSTIC OVARY SYNDROME Mahmoud Aljubeh, MD
OBGYN specialist

2. INTRODUCTION
PCOS is a common endocrinopathy typified by oligoovulation
or anovulation, signs of androgen excess, and multiple small
ovarian cysts.
It’s the most common endocrine disorder affecting women of
child bearing age

3. DIAGNOSIS
ROTTERDAM CRITERIA
(1) oligo- and/or anovulation
(2) hyperandrogenism (clinical and/or biochemical)
(3) polycystic ovaries identified by ultrasound
(12 or more follicles in each ovary less than 10 mm or ovarian volume more
than 10 cm3 )
(4)exclusion of other causes :
as congenital adrenal hyperplasia, androgen-secreting tumors, and
hyperprolactinemia, may also lead to oligoovulation and/or androgen excess

4. ANOVULATION
Arrested antral follicle
Chronic hyper-estrogenemia (increased estrone and estradiol)
Amenorrhea , oligomenorrhea and sometimes menorrhagia

5. ANDROGEN EXCESS
Clinical : hirsutism , acne , androgenic alopecia
Biochemical : increased androgen level as testestrone , androstendione

6. DIAGNOSIS
The presence of a single polycystic ovary is
sufficient to provide the diagnosis.
The distribution of the follicles and the
description of the stroma are not required in
the diagnosis.
Polycystic ovaries are commonly detected by
ultrasound or other forms of pelvic imaging,
with estimates of the prevalence in the
general population being in the order of 20–
33%

7. PATHOPHYSIOLOGY
❖Altered GnRH pulsatility
Increased LH to FSH ratio above 2:1
❖Insulin resistance : compensatory hyperinsulinemia , risk of DM2 , dyslipidemia
and CVD
Both insulin and LH stimulate androgen production by the ovarian theca cell ----
hyperandrogenemia
Decreased SHBG : The synthesis of SHBG is suppressed by insulin as well as androgens,
corticoids, progestins, and growth hormone
Therefore more free androgen (active )
❖Anovulation: Progesterone levels are low due to anovulation

8. SERUM ENDOCRINOLOGY :
↑ Fasting insulin
↑ Androgens (testosterone and androstenedione)
↑ Luteinizing hormone (LH), usually normal follicle stimulating hormone (FSH)
Decrease Sex hormone binding globulin (SHBG), results in elevated ‘free
androgen index’
↑ Oestradiol, oestrone (neither measured routinely as very wide range of
values)
↑ Prolactin

9. CONSEQUENCES OF PCOS
❑OBESITY
❑INFERTILITY (anovulation )
❑GLUCOSE INTELORENCE AND DM2
❑DYSLIPIDEMIA
❑CVD
❑ENDOMETRIAL CANCER :
unopposed estrogen leading to endometrial hyperplasia
❑PREGNANCY COMPLICATIONS :
pregnancy loss , Increased gestational diabetes, pregnancy-induced
hypertension, preterm birth, and perinatal mortality

10. MANAGEMENT
Depends on the goal of treatment of each patient
and
Management of complications

11. MANAGEMENT
MENSTRUAL IRREGULARITY
✓Encourage weight loss
✓Cyclic combined oral contraceptive preparation
✓progestogen (such as medroxyprogesterone acetate or
dydrogesterone and Mirena LNG-IUS

12. MANAGEMENT
HYPERANDROGENISM
Please note that Women with PCOS do not become virilized (i.e. do not
develop deepening of the voice, increased muscle mass, breast atrophy or
clitoromegaly)
Signs of hyperandrogenemia includes hirsutism and acne
Hirsutism is characterized by terminal hair growth in a male pattern of
distribution, including chin, upper lip, chest, upper and lower back, upper and
lower abdomen, upper arm, thigh and buttocks.
Hirsutism evaluated and scored by modified Ferriman and Gallwey score

13. MANAGEMENT
HYPERANDROGENISM
(HIRSUTISM )
❖Physical treatments including electrolysis, waxing and bleaching, Laser and
photothermolysis
❖cyproterone acetate
❖Spironolactone : a weak diuretic with antiandrogenic
❖Drosperinone is a derivative of spironolactone and contained in the new COCP
❖Antiandrogens as finasteride and flutamide
Contraception is needed when antiandrogen is used

15. MANAGEMENT OF THE
COMPLICATIONS
▪Screening for glucose intolerance , DM , dyslipidemia and CVD
▪Regular shedding of the endometrium with OCP , progesterone or MIRENA
to decrease the risk of endometrial cancer with low threshold to take a
biopsy if symptomatic, thick endometrium, high risk patient (obese ,HTN ,
dyslipidemia ) or failure of treatment
▪Metformin is to be given if glucose intelorence
▪Statin in dyslipidemia
▪Weight reduction with dietary modification , drugs or surgery of MBI is more
than 35 or accompanied with co-morbidities

16. MANAGEMENT OF THE
COMPLICATIONS
INFERTILITY
The aim is to induce ovulation
A. Weight reduction
B. clomiphine citrate (first line medical treatment )
C. clomiphine citrate + metformin *??
D. Parenteral Gonadotropin
E. Laparascopic Ovarian drilling or IVF