Polycystic ovary syndrome (PCOS) is characterized by ovulatory dysfunction and hyperandrogenism. It is the most common cause of infertility in women. Early diagnosis is important due to long term risks like diabetes and heart disease. Diagnosis involves abdominal ultrasound showing polycystic ovaries and signs of excess androgens. Management includes lifestyle changes like diet and exercise for weight loss. Pharmacological treatments include combined oral contraceptives to regulate menstrual cycles and reduce androgens. Metformin may also be used to lower insulin levels and androgens. For severe hirsutism, laser hair removal or electrolysis can be considered.

1. POLYCYSTIC OVARY SYNDROME

2. CONTENTS
 INTRODUCTION
 ESSENTIAL COMPONENTS
 PATHOPHYSIOLOGY
 DIAGNOSTIC CRITERIA
 CLINICAL FEATURES
 DIFFERENTIAL DIAGNOSIS
 DIAGNOSIS
 MANAGEMENT

3. INTRODUCTION
• Polycystic ovary syndrome (PCOS) is the most common cause
of infertility in women
• Frequently seen in adolescence
• Primarily characterized by ovulatory dysfunction &
hyperandrogenism
• Consequences  Increased risk for metabolic syndrome, type
2 diabetes mellitus, cardiovascular disease & endometrial
carcinoma
• Prevalence of PCOS in Indian adolescents is 9.13%
Prevalence of polycystic ovarian syndrome in Indian adolescents
Nidhi R, Padmalatha V, nagarathna R, Amirtanshu R. J. Pediatr. Adolesc Gynecol 2011 Aug;24(4):223-7.

5. • In 1935, Stein and Leventhal
described 7 women with
bilateral enlarged PCO,
amenorrhea or irregular
menses, infertility and
masculinizing features.
• This paper introduced
clinicians to the concept of
reproductive
endocrinopathies
Stein and Leventhal

6. Other names
• Polycystic Ovarian Syndrome,
• Functional Ovarian Hyperandrogenism,
• Chronic Hyperandrogenic Anovulation,
• Ovarian Hyperandrogenic Dysfunction,
• Hirsutism-Anovulation Syndrome,
• Stein Leventhal Syndrome,
• PCO
• PCOD
• Polycystic Ovaries
• Sclerocystic ovary
• Stein’s Syndrome

7. ESSENTIAL COMPONENTS
POLYCYSTIC
OVARY
SYNDROME
HYPERANDROGENISM
ANOVULATION
OBESITY
POLYCYSTIC
OVARIES ( ONE OR
BOTH)

10. CLINICAL FINDINGS
• Cutaneous manifestations
of hyperandrogenism
• Hirsuitism:- Commonly
graded according to the
Ferriman-Gallwey
systemthe extent of hair
growth in the most
androgen-sensitive areas

11. • Acne :- Acne vulgaris is
an important cutaneous
manifestation of
hyperandrogenemia in
adolescents
• Seen in approximately
one-third or more of
PCOS patients
• Primarily affects the
face, less often, the
back and chest

12. • Androgenic Alopecia
• Progressive, non-scarring, patterned loss of scalp
terminal hairs.
• Male-pattern (affecting the fronto-temporo-occipital
scalp)
• Female-pattern (affecting the crown. "Christmas
tree" pattern)

13. Ovarian findings

14. Obesity
• PCOS most common obesity-related endocrine
syndrome in females
• Present in approximately one-half of patients.
• Central (android) obesity is common
• Defined by a waist circumference ≥88 cm in
adolescents as well as adult women

15. INSULIN RESISTANCE
• Commonly seen in adults with PCOS
• Increased risk for glucose intolerance
• Glucose tolerance progressively deteriorates over
time
• Approximately 10% develop DM by 40 yrs of age
• Clinical manifestations of insulin resistance include
acanthosis nigricans & metabolic syndrome

17. • Acanthosis nigricans – Indicator of insulin
resistance and may be the presenting
complaint of patients with PCO

18. Metabolic syndrome
• Results from the interaction of insulin resistance with
obesity and age
• Co-occurrence of metabolic risk factors for type 2
diabetes & cardiovascular disease, including
abdominal obesity, hyperglycemia, elevated
triglycerides, low HDL cholesterol, and hypertension.
• Approximately 25 %of adolescents with PCOS have
metabolic syndrome

19. Differential diagnosis
1. Virilizing congenital adrenal hyperplasia
2. Cushing’s syndrome
3. Virilizing tumors
4. Hyperprolactinemia
5. Insulin-resistance disorders
6. Acromegaly
7. Thyroid dysfunction
8. Drugs

20. DIAGNOSIS
• History and physical examination
• Cutaneous manifestations of
hyperandrogenism provide clinical evidence
of hyperandrogenism
• History of medications

21. ULTRASONOGRAPHY
 Done to R/O rare but serious adrenal or ovarian
tumor & ovarian pathology not related to PCOS
 Determination of polycystic ovaries
 Pelvic pathology ovotesticular disorder of sex
development & functional hyperandrogenism of
pregnancy -detected by ultrasonography
 Patient reassurance and education

22. USG
• B/L enlarged ovaries with
multiple small follicles
• Peripheral location of
follicles:-string of pearl
appearance
• 12 or more follicles
measuring 2-9 mm
• Hyperechoic central stroma
• Irregular ovarian outline

24. TESTING FOR HYPERANDROGENEMIA
• Done by testosterone levels
• Total testosterone & Free testosterone
• Normal upper limit for serum total testosterone in
adult women is approximately 40 to 60 ng/dL (1.4 to
2.1nmol/L)
• Serum testosterone concentrations 29 to
150 ng/dL (1.0 to 5.2 nmol/L)
• Total testosterone >200 ng/dL (6.9 nmol/L)

25. • Dehydroepiandrosterone sulfate (DHEAS) –marker
for adrenal hyperandrogenism
• Used to detect adrenal tumor
• Adrenal tumorDHEAS levels are often markedly
elevated (>700 mcg/dL, 13.6 mmol/L)

26. Laboratory Tests
• FSH - will be normal or low with PCOS
• LH (Lutenizing Hormone) - will be elevated
• LH/FSH ratio - This ratio is normally about 1:1 in
premenopausal women, but with PCOS a ratio of
greater than 2:1 or 3:1 may be considered diagnostic.
• Prolactin - will be normal or low (elevated in
hyperprolactinemia)
• Estrogens - may be normal or elevated
• hCG (Human chorionic gonadotropin) - used to check
for pregnancy; negative unless pregnant

27. • Lipid profile (low HDL, high LDL & cholesterol,
elevated triglycerides)
• Glucose - fasting and/or a glucose tolerance test;
may be elevated
• Insulin - often elevated
• TSH (Thyroid stimulating hormone) - to check
thyroid function
• Free cortisol & creatinine levels - rule out Cushings
syndrome
• 17-hydroxyprogestrone- to rule out congenital
adrenal hyperplasia

28. MANAGEMENT

29. NON PHARMACOLOGICAL
• Nonpharmacologic measures are universally
recommended.
– These measures include the following(Lifestyle Measures):
 Diet including seeing a dietician who is knowledgeable
in PCOS
 Exercise
 Weight Reduction if the patient is obese or insulin-
resistant.

30. Life style modification & weight loss
in PCOD
• Risk modification and symptom relief (e.g.,
restoration of ovulatory cycles) has clearly
been achieved with lifestyle modification and
weight loss
• All strategies for weight loss, including surgery,
need to be explored in PCOS patients.

31. • Combination of weight-reducing medications
and group lifestyle modification was shown to
be more effective than either alone, in a group
of obese adults.

33. • Bariatric surgery as treatment for obesity is
highly relevant to the PCOS population
• Shown to reverse much of the metabolic, as
well as the reproductive problems , including
hirsutism.

35. MEDICAL MANGEMENT
Oral contraceptive pills
• 1st line treatment
• Correct both menstrual abnormalities and
hyperandrogenemia
• Estrogen-progestin combination suppresses the
hypothalamic-pituitary-ovarian axis & reduces excess
androgen production by the ovary
• Progestin component inhibits endometrial proliferation
→prevents hyperplasia and the associated risk of
carcinoma

37. Limitations
• Fourfold increased risk of venous
thromboembolism in first-time users
• Contraindicated in perimenarcheal girls with short
stature- growth-inhibitory amounts of estrogen
• Belief of curative treatment and defer in follow-up
• Do not permit conception if and when it is desired.

40. HIRSUITISM
• Not controlled satisfactorily within six months by the
hormonal treatments→ additional methods used
• Cosmetic measures:- shaving, chemical depilatory agents,
bleaching, and waxing techniques
• Eflornithine hydrochloride cream (Vaniqa) removal of
unwanted facial hair in women.
• It inhibits hair growth and takes about six to eight weeks for
clinical effect.
• It needs to be used indefinitely to prevent regrowth

41.  Laser therapy:- Permanent hair removal by dermal
papillae destruction
 Electrolysis :- Permanent hair removal by dermal
papillae destruction .
• Slow, expensive therapy that can occasionally cause
scarring

43. Oral hypoglycemic agents
• Metformin :- Reduces insulin concentrations, promotes
ovulation, and lowers androgen levels
• Does not improve hirsutism
• Metformin tends to suppress appetite and slightly enhance
weight loss
• Abnormal glucose tolerance is the only approved indication
for metformin
• Lowers testosterone levels by 20 %

44. • A recent, uncontrolled, retrospective, observational
study, shows that long-term treatment with
metformin delays or prevents the development of
impaired glucose tolerance and diabetes in women
with PCOS
Sharma ST,Wickham III EP, Nestler JE. Changes in glucose tolerance with metformin treatment in
polycystic ovary syndrome: a retrospective analysis. Endo. Prac. 13(4), 373-379 (2007).

47. Laparoscopic surgery
• Surgical approaches to restoring ovulation in women
with PCOS date back to the 1930
• B/l ovarian wedge resection used
• Complications→ post op adhesion formation
• Laproscopic surgery currently employed
• Sr androstenedione ↓
• Sr LH, testosterone, and inhibin concentrations ↓
• Sr FSH concentrations ↑

48. • Methods:- Electrocautery (also known as diathermy),
laser "drilling," & multiple biopsy

49. Summarize
• Polycystic ovary syndrome (PCOS) is the most
common cause of infertility in women
• Frequently seen in adolescence
• Early diagnosis is important because of the
potential long-term consequences
• Primarily characterized by ovulatory
dysfunction & hyperandrogenism
• Diagnosis- USG abdomen showing polycystic
ovaries

50. • Management- Includes Non pharmacological(
weight reduction, diet and exercise) &
pharmacological ( Combined OCPs and
Metformin)
• Surgery:- Electrocautery, laser drilling &
multiple biopsy

51. September is PCOS Awareness Month

52. THANK YOU