Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women, affecting around 1 million females in Germany. It is characterized by menstrual irregularities, excess androgen levels, and polycystic ovaries. PCOS causes infertility due to chronic anovulation from hyperandrogenism and insulin resistance. Women with PCOS have an increased risk of obesity, diabetes, cardiovascular disease, and other metabolic complications. The cause of PCOS involves genetic and environmental factors, and its features vary in severity and combination of symptoms between individuals.

1. Polycystic ovarian syndrome
Zoltán Garamvölgyi M.D.

2. Polycystic ovarian syndrome (PCOS)
Most common female endocrin disorder, eg. in German 1 million females
1921. C. Achard and J. Thiers: 7 obese women with hirsutism
Hyperandrogenism associated with carbohydret disorder
„Diabetic women with moustaches“
1935. Stein and Leventhal „polycystic ovaries, hirsutism, amenorrhea, obesity”
(may occur in women without ovarian cysts)
Menstrual cycle disorders and infertility due to hyperandrogenism and
chronic anovulation

3. NIH (United States National Institutes of Health) 1990.
oligo-ovulation or anovulation (oligomenorrhea, amenorrhea)
hyperandrogenism (clinical or/and biochemical evidence of androgen excess)
exclusion of other disorders (menstrual irreg., hyperandrogenism)
Diagnostic criteria
The Androgen Excess and PCOS Society (AE-PCOS) 2006.
Oligo-ovulation and/or polycystic ovaries
Clinical/biochemical evidence of hyperandrogenism
Exclusion of related disorders PCOS, Rotterdam-criterions 2003
(ESHRE/ASRM)
Diagnosed when 2 of the 3 criterions fulfilled:
1. chronic anovulation (oligo- or amenorrhea)
2. Clinical and/or biochemical
hyperandrogenism
3. polycystic ovaries

4. United States: 4-12%, European countries: 6,5-8%
Ethnic variability in hirsutism
Asian: less hirsutism than white women given the same serum androgen values.
In hirsute women: sign. increase in the incidence of acne/menstrual
irregul./polycystic ovaries/acanthosis nigricans
PCOS affects premenopausal women
The age of onset is perimenarchal.
(fast mature of reproductive axis/weight gain,
less exercise unmaskes PCOS, early manifestation)
Epidemiology

5. High serum cc. of androgenic hormones (testosterone,
androstendione, DHEAS)
Individual variation (might have normal androgen levels)
Peripheral insulin resistance and hyperinsulinemia
Obesity
Etiology

6. Etiology
direct effect on muscle/fatty tissue/liver/ovaries (theca and granulosacells)
Insulin resistance:
Secondary to a postbinding defect in insulin rec. signaling pathways
Supression of hepatic generation of SHBG
Supr. of adiponectin (regulates of lipid metab. and glucose levels)
Increased production of IGF-1
Dyslipidemia
PAI-1 increasing (plasminogen activator inhibitor) (risk for thrombosis)
Insulin

7. Etiology
Hyperinsulinemia not equal with PCOS.
Not every PCOS women have IR.
(genetic background, gene polymorphism:
cysteinprotease Calpain 10, proinsulin,
insulinrec. (IRS-1, IRS-2)

8. PCOS: not a consequence of IR!
Theca + granulosacells have inzulinreceptors:
Insulin is in synergism with LH.
Rec.: insulin + IGF-1.
The androgen production increases.
Effect on the ACTH- cortisol axis,
facilitats the androgen production of the adrenalgls.
Insulin enhances the sensitivity of the gran.cells to the FSH:
the number of the follicles increase
Enhanced IR: anovulatorical cycles + hyperandrogenism
Damage of the postreceptor pathway of the insulin!

9. Normal: IRS1 activates the PI3: the intracellular glucose transport increases.
PCOS:
the autophosphorisation of the tyrosin decreases,
the serin phosphorilisation increases
Activation of the cytochrom P450c17α (adr.glands + ovaries)
– level of the androgens increases.
Insulin blocks the production of the IGFBP-1 of the liver: IGF-1 cc. increases
Effect on the granulosacells + thecacells (LH and androgens cc. increase).
Obesity and PCOS:
normal LH cc. can also enhances
the receptors of the LH and the sensitivity of the ovaries to the LH
25 % of the hyperandrogenism of the PCOS is due to the adr.glands!
Peripherial androstendion transforms to testosteron and DHT (5α-reductase)

10. Ovarial effect of the insulin
 Acts on atypical IGF receptors
 Upregulation of the IGF-I receptor
 Decreases of the IGF-bp cc.
 Synergism with the IGF-I and LH
in the androgen production
Hypophyseal effect of the insulin
Anovulation
Endometrial effect of the insulin
Blocks the implantation

11. Etiology Hypothalamic intrinsic disorder + low progesteron cc.
Decreased progesteron-sensitivity?
(Flutamid- androgen rec. antagonist-increases prog.sensitivity)
GnRH-puls frequence increasing
Pituitary: LH increasing (LH>FSH)
Ovaries: theca-cells: cytochrom P450 c17 (17α-hydroxylase + 17,20 lyase activity)
Androstendion production
17β-hydroxysteroid-dehydrogenase
Testosteron
oestrogen cc. increases
Gran.cells: FSH decreases

12. „Two cells- two gonadotropins „ hypothesis
LH
LH-receptor
FSH
FSH-receptor
ATP cAMP
cholesterin
androstendion
Blood vessels
androstendion estrogen
aromatase enzyme
ATP cAMP
Fluid of the follicles
LH-receptor
thecacells
granulosacells

13. Genetically heterogeneous syndrome
Difficult condition to study genetically, candidate
gene?
Fathers of PCOS women: can be abnormal hairy
Mothers: oligomenorrhea
Family history of type2 diabetes in a first-degree
family member
Dutch twin-family study: PCOS heritability of 0,71 in monozygotic twin sisters
Link between PCOS and obesity, associated genes:
FTO-gene
CYP17 promoter activity 4x in cells of PCOS women
Homozygous for an allele of interest in IGF2
(stimulates androgen secretion in the ovaries and adrenal glands)
Genome-wide association:
Chinese population: 2p16 locus:
near genes formate testis/encode LH-rec and hCG.
Near FSHR gene (encodes FSH-receptor)
Family history:
•Menstrual disorders
•Adrenal enzyme deficiences
•Hirsutism
•Infertility
•Obesity and metabolic sy.
•Diabetes

14. Intrauterin environment
Maternal:
Diabetes
GDM
PCOS
Obesity
Hypothyreoidism

15. GnRH/LH ↑
PCO PCOS
Chronical anovulation
Insulinresistance Hyperandrogenism
Serotonin↓
GABA↑
Pathomechanism of the PCOS
Dopamin ↓ Opioids ↓
Burghen et al: JCEM 1980, 50, 113
Depressive disorders:
35 % (3X)

17. Phenotypes of the PCOS
Hyperandrogenism + not obes + non IR Extrem obesity + IR +
hyperandrogenism
PCOS Severe
(complet)
Fourth
phenotype
Ovulation Mild
(non hyperandrogenic)
Bleeding irregular irregular reggular irregular
UH PCO normal PCO PCO
Androgen cc. high high high Minimal increased
Insulin cc. low high high Normal
Frequency 61% 7% 16% 16%

18. Metabolic disorder > Metabolic disorder
Hyperandr./hirsut. Hyperandr./hirsut.
Oligoanovulátion Ovulatory ciclus
PCO-form
Hyperinsulinaemia > Hyperinsulinaemia
Metabolic sy.: 42,3 %
2TDM : 3-6 %
signs A B C D E F G H I
Hyperandr + + + + - - + - +
Hirsutismus + + - - + + + + -
Oligoanov + + + + + + - - -
PCO. + - + -
+ - + + +
AES, 2006.

19. 0
10
20
30
40
50
60
70
80
90
100
Norm Non
PCOS
obes
PCOS
thin
PCOS
obes
Insulin sensitivity

20. Signs Frequency
sterility 74%
hirsutism 68%
Irregular bleeding 52%
obesity 44%

21. Bilaterally or unilaterally enlarged, polycystic ovaries
Hyperplasia of the theca stromal cells surrounding arrested follicles
80-100 % of all PCOS women.
Enlarged ovaries not always be present.
>= 12 follicles (2-8 mm in size)
23 % of women with normal menstrual cycle have polycystic ovaries.
Enlarged, polycystic ovaries
Anovulation, monophasic cycle, disorder of the selection of the
follicules because of the prolonged follicular menstrual phase
Overstimulation, twin pregnancies
75 %

22. Chronic anovulation (menstrual disturbance in premenarche)
Oligomenorrhea (menstr. bleeding occurs at intervals of 35 days
to 6 months, < 9 menstrual periods per year)
Secondary amenorrhea (an absence of menstruation for 6
months)
Ovulatory and menstrual dysfunction 75%

23. 75 % of PCOS women:
primaer or secondary sterility
due to anovulation
Rate of miscarrieges is high: 25-44%
Infertility

24. ABORTUS SPONTANEUS Maternal Chr. Subclinical
inflammation
Embryo/fetus?
Habitualis ab.: 40-80 % of PCOS!
LH: effect on to the implantation (non PCOS vs PCOS= 12-15% vs 30-50%)
Uterinal factor: perifollicular bloodcirculation worse
Folliculus gene expression (androgén hatás)
IGF-1: Y IGF-1 rec. downregulation
(morula’s gl.uptake decreases before the implantation)
GLUT-4 (cc. decr.)
IGFBP-1(cc.decr.) implantation/adhesion romlik

25. Diabetes Prevention Program (DPP)
Troglitazine in prevention of Diabetes (TRIPOD)
Metformin and PCOS
CC CC + metformin
Ovulation 42 % 76 %
More effective:
>28 age + visceral.fatty tissue
(p<0,001) CC CC + metformin metformin
Pregnancy 22,5 % 26,8 % 7,2 %

26. Metformin és PCOS
Diabetes Prevention Program (DPP)
Troglitazine in prevention of Diabetes (TRIPOD)
Ab.spontaneus Metformin vs. placebo Odds r. 0,36, 95% CI, 0,09-1,47
CC vs. CC + metformin Odds r. 1,61, 95% CI, 1,00-2,60
No advantage
Metformin placebo
PE 7,4 % 3,7 % P=0,18
GDM 17,6 % 16,9 % P=0,87
Premature
labour
3,7 % 8,2 % P=0,12
Σ 25 % 24,4 % P=0,78
Previous GDM:
metformin mitigates 2TDM risk 50 % vs 14 %

27. excess terminal body hair in a male distribution pattern
(upper lip, chin, nipples, linea alba, lower abdomen)
acne
androgenic alopecia
other signs: clitoromegaly+ increased mucle mass + voice
deepening
(extreme forms of PCOS, hyperthecosis or androgen-producing
tumors, virilizing congenital adrenal hyperplasia)
Hyperandrogenism 60-80%

28. Female type of metabolic sy.?
Manifestation: later than acne or hirsutism.
50% of PCOS women are obese.
28 % of all obese women suffered from PCOS.
American PCOS women have a
higher BMI than italian PCOS women.
PCOS: obesity and metabolic syndrome
43% prevalence of metabolic syndrome, characterized by:
abdominal obesity (waist circumference: >88 cm.)
dyslipidemia (TG level > 150 mg/dL)
High-density lipoprotein cholesterol (HDL-C) level <50 mg/dL
elevated blood pressure (> 130/85 mmHg)
IFG or IGT
(>=3: metabolic sy. )
+: elevated C-reactive protein level, elevated plasminogen
activator inhibitor-1 (PAI-1), fibrinogen levels.

29. 1/3 of PCOS women had IFG or IGT within 13-19 years old
40% of patients with PCOS have insulin resistance that is independent of body weight.
(increased risk for type 2 diabetes and cardiovascular complications)
American Association of Clinical Endocrinologists:
screening for diabetes by age 30 years in all patients with PCOS!
Should be periodically reassessed throughout their lifetime.
Every 3-5 years screening for diabetes!
PCOS: obesity and metabolic syndrome

30. PCOS: obesity and metabolic syndrome
Diabetes mellitus:
Insulin resistance compensated long in most PCOS women.
(problem in women with positive familiy history.)
2 type diabetes risk: 7x
10% of women with PCOS have type 2 diabetes mellitus
30-40 % of women with PCOS have impaired glucose tolernace (IGT)
by 40 yeares of age
Screening with OGTT. Early diagnosis. Latens state of insulin resistance will
changed to manifested IR in GDM/th. with glucocorticoids
HOMA-index:
normal ≤ 1
suspicious of IR: > 2
posibility of IR: > 2,5
diabetes mellitus: > 5

31. Elevated serum lipoprotein levels
Lean PCOS women: also endothelian dysfunction (thickened intima media)
CRP and endothelin-1 increase
Coronarian diseases and macroangiopathy:
TG/LDL increase, HDL level decreases
coronary artery calcification
Risk for AMI:
7X in women at age of 40-60 years
Sleep apnea: obstructive sleep apnea syndrome (OSAS)
An independent risk factor for cardiovascular disease. (excessive daytime somnolence)
HypoD-vitamism (73%)
Vit.D-gene regulates 3% of the human genom
(glucose/lipid/ metabolism/blood pressure)
Decreased D-vit. level associated with
•Dylipidemia
•Insulin resistance
•Obesity
Risk for cardiovascular and cerebrovascular disease

32. Increased risk for endometrial hyperplasia and carcinoma.
(constant endometrial stimulation with estrogen without progesterone).
Recommended induction of withdrawal bleeding with progesterons a
minimum of every 3-4 months.
No known association with breast or ovarian cancer has been found.
Carcinoma

33. common symptom of PCOS.
Rare in japanese women with PCOS.
(In caucasian PCOS women: 9% hirsutism)
In the skin-cells:
testosteron ---- 5α-reductase ---- dihydrotestosteron (DHT)
the enzyme is activated by insulin/IGF-1/androgens
Physical examination
Hirsutism and virilizing signs
Hirsutism: 60 %

34. 1961: Ferriman-Gallwey score (9 body areas. 0 (no hair) to 4 (frankly virile))
upper lip, chin, chest, upper and lower abdomen
thighs, upper and lower back, arm, forearm, buttocks.
>=8: hirsutism
A total score of 8 or more: abnormal for an adult white women
Score of 44: most severe
The modified Ferriman-Gallwey score grades 11 body areas.

35. Acne:
12 % of all adult women
23-35 % of all PCOS women.
Androgen alopecia: 5 %
not common, responsible is the DHT (+ ovarian and adrenal
androgenes)
Physical examination
Hirsutism and virilizing signs

36. Diffuse, velvety thickening and hyperpigmentation of the skin
Present at the nape of the neck/axillae/beneath the breasts/intertriginous
areas/exposed areas (elbows, knuckles)
Result of insulin resistance.
Can also be a cutaneous marker of malignancy!
Physical examination Acanthosis nigricans
Scoring system:
Absent (0)
Present (1): on close visual inspection, extent not measurable
Mild (2): limited to the base of the skull (does not extend tot the lateral margins of the neck)
Moderate (3): extends tot he lateral margins of the neck
Severe (4): visible anteriorly
Severe (5): circumferential

37. PCOS
appearance
forms
Hyperandrogenism,
acne, hirsutism
,acanthosis nigricans
alopecia
Menstruation disorder,
oligo/anovulation and
Sterility
Psychological
problems,
Depression
dermatologist
endocrinologist
Diabetologist
Endocrinologist
Gynecologist
Psychologist
Insulin resistance
Hyperinsulinism
2TDM
Worsening follicles
quality
Unsuccessful ART
IVF
specialist

38. PCOS: else metab./endocrin. disorders
CRH-ACTH-kortizol axis activated
Hyperreninaemia/hyperaldosteronismus
PRL 2-3X
PAI-1/fibrinogen incr.
Hyperuricaemia/homociszteinaemia
Ferritin cc. Incr. (storage of iron incr.)
NAD(P)H-oxidase aktiv.
Szuperoxid freeradical incr.
obesity
Musculature: gl.uptake decr.
Liver: inz.metab.decr.
IR
GI tr.:
Iron uptake incr.

39. Diagnosis of the PCOS
testosterone (total or free) and SHBG
Free Androgen Index (FAI).
FAI = total testosterone [nmol/l] x 100 / SHBG [nmol/l]
LH, FSH, estradiol, progesteron, prolaktin, TSH
17-OH progesteron, androstendion, DHEAS, basal cortisol
LH>FSH (2x-3x): seeing in follicule phase of the menstrual cycle
OGTT
Liver enzymes, kidney function, serum ions

40. LHRH-test: 25 ug Buserelin iv. 0-30-60 min.
(GnRH-analog: the constans stimulation of the pituitary
decreases LH and FSH secretion)
LH level increasing > FSH level increasing (not diagnostic)
Diagnosis of PCOS

41. DD.:
Ovarian hyperthecosis (luteinized cells throughout the stroma)
Congenital adrenal hyperplasia (late-onset)
Drugs (Danazol, androgenic progestins)
Hypothyroidism
Idiopathic/familial hirsutism
Masculinizing tumors of the adrenal gland or ovary (rapid onset of signs of virilisation)
Cushing –sy. (low K+, striae, central obesity, high cortisol, high androgens)
Hyperprolactinemia
Exogenous anabolic steroid use
Stromal hyperthecosis (valproic acid)
Diagnostic considerations

42. Therapy of the PCOS
Variability of the clinical symptomps!
Fit the therapy to the
• Actuel symptomps (hirsutism, acne etc.)
• Wishes (contraception, pregnancy)
• Different life periods (adolescence, praemenopausa, postmenopausa)

43. Oral contraceptive pill
estragens: LH level decreases/SHBG level increases
but: insulin resistance and cardiovascular risk enhanced
(recommended progestin only pill)
progestins:
II.generations of the progestins- levonogestrel- have androgen effect!
cyproteron acetat Le Figaro: „Sept décès en France liés à la pilule Diane 35”
dienogest
spironolacton
flutamid (non steroid antiandrogen drug: very effective, but hepatotoxic effect)
Glucocorticoids (Lowers only adrenal glands –DHEA,DHEAS, androstendion-
androgens level)
Finasterid (non steroid antiandrogen drug: benign hyperplasia of prostata,
against adrogen alopecia)
Therapy of the PCOS

44. Induce the sensitivity of insulin
by more exercise/life style modifications/insulin sensitisers
Insulin sensitisers:
Metformin
(contraindicated the use of it in pregnancy in Hungary/German)
Thiazolid
troglitazon: effective, but hepatotoxic (1997.: prohibited in the U.K.)
rosiglitazon: not hepatotoxic, but increase the liver enzymes reversible.
Enzyme inhibitors:
Acarbose /Glucobay/
Lowers the enteral uptake/absorption of glucose, lowers the postprandial
hyperinsulinemia
Reversible blocks (competetive antagonism) the α-glucosidase-hydroxylase
enzyme of the bowel-musosa.
Flatulation, tenesmus, diarrhea!
Therapy of the PCOS

46. Inositol:
6-C-atoms, cyclic polyalcohol.
9 stereo-isomer known
myo-inositol:
The most frequent natural form

47. • Intracellular Ca2++ cc. control
– Maintenance of the cellular membranpotential
• Metabolic effects
– Insulin signal transduction
– Lipolysis , serum cholesterin cc. decreasing
• Other
– Serotonin activity modulation
– Nervous system regulation
• Gen expression
Function of the inositol
Signal transmission and sec. messenger

48. Inositol-foszfolipid-
Ca++ as sec.
messenger
OOCYTA evolution
OOCYTA
Maturity
FERTILISATION
(early stadium)

49. Therapy of the PCOS
Clomiphen-resistance: laparoscopic ovarian drilling
ovulation increasing (30% to 90%)
possibility of gravidity increasing (13,5 to 88 %)

50. METFORMIN (biguanid)
PRO: Insulinsensitiser
KONTRA: Off label use, GI side effects
CLOMIPHENE CITRATE
PRO: Anti-oestrogen, stimulation of the FSH, LH secretion
KONTRA endometrium atrophied
EXOGEN GONADOTROPIN
PRO: direct effect on the ovaries, subcutan injection,
monitorisation of its effect by ultrasound
KONTRA Ovarium hyperstimulation syndrome
Combined therapy:
Metformin + clomiphen citrate:
>28 years, waist-hip ratio is high
(metformin therapy decreases the development of the hyperstimulation)
Ovulation:
60-85 %
Pregnancy:
30-50 %
After 6 ovulatory cycles