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GY24 Gynecology
Polycystic Ovarian Syndrome
Toronto Notes 2019
PCOS May be Confused with
• Late onset congenital adrenal hyperplasia (21-hydroxylase deficiency)
• Cushing’s syndrome
• Ovarian and adrenal neoplasms • Hyperprolactinemia
• Hypothyroidism
Clinical Signs of Endocrine Imbalance
• Menstrual disorder/amenorrhea (80%) • Infertility (74%)
• Hirsutism(69%)
• Obesity (49%)
• Impaired glucose tolerance (35%) • DM(10%)
Long-Term Health Consequences
• Hyperlipidemia
• Adult-onset DM
• Endometrial hyperplasia • Infertility
• Obesity
• Sleep apnea
Insulin-Sensitising Drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for Women with Polycystic Ovary Syndrome, Oligo Amenorrhoea and Subfertility
Cochrane Database Syst Rev 2012; (5):CD003053 Purpose: To evaluate efficacy of insulin-sensitising drugs in improving reproductive outcomes of women with PCOS.
Methods: 42 RCTs (n=3992) were included. Conclusions: Metformin was associated with improved clinical pregnancy rates whether used alone or in combination with clomiphene. However, this did not translate into live birth rates.
Diagnostic Criteria for Polycystic Ovary Syndrome: Pitfalls and Controversies
JOGC 2008;8:671-679
At present, there is no clear-cut definition of biochemical hyperandrogenemia, particularly since there is dependence on poor laboratory standards for measuring androgens in women. Clinical signs of hyperandrogenism are ill-defined in women with PCOS, and diagnosis of both hirsutism and polycystic ovarian morphology remains subjective. There is also the inappropriate tendency to assign ovulatory status solely on basis of menstrual cycle history or poorly timed endocrine measurements. Therefore it is important as clinicians to recognize the multi-factorial and complex nature of PCOS and place this in the context of our present diagnostic limitations.
Diagnosis
• Rotterdamdiagnosticcriteria:2of3required ■ oligomenorrhea/irregular menses for 6 mo ■ hyperandrogenism
◆ clinical evidence - hirsutism or acne
◆ biochemical evidence - raised free testosterone
■ polycystic ovaries on U/S (not appropriate in adolescents)
Clinical Features
• averageage15-35yratpresentation
• inadolescents,waitatleast1-2yrtomakediagnosisasadolescenceresemblesPCOS
• abnormal/irregularuterinebleeding,hirsutism,infertility,obesity,virilization
• acanthosisnigricans:browningofskinfoldsinintertriginouszones(indicativeofinsulinresistance) • insulinresistanceoccursinbothleanandobesepatients
• family history of DM
Investigations
• goal:identifyhyperandrogenismorchronicanovulationandruleoutspecificpituitaryoradrenal disease as the cause
• laboratory
■ prolactin, 17-hydroxyprogesterone, free testosterone, DHEA-S, TSH, free T4, androstenedione,
SHBG
■ LH:FSH >2:1; LH is chronically high with FSH mid-range or low (low sensitivity and specificity) ■ increased DHEA-S, androstenedione and free testosterone (most sensitive), decreased SHBG
• transvaginal or transabdominal U/S: polycystic-appearing ovaries (“string of pearls” – 12 or more small follicles 2-9 mm, or increased ovarian volume)
• testsforinsulinresistanceorglucosetolerance
■ fasting glucose:insulin ratio <4.5 is consistent with insulin resistance (U.S. units) ■ 75 g OGTT yearly (particularly if obese)
• laparoscopy
■ not required for diagnosis
■ most common to see white, smooth, sclerotic ovaries with a thick capsule; multiple follicular cysts in
various stages of atresia; and hyperplastic theca and stroma • rule out other causes of abnormal bleeding
Treatment
• cyclecontrol
■ lifestyle modification (decrease BMI, increase exercise) to decrease peripheral estrone formation ■ OCP monthly or cyclic Provera® to prevent endometrial hyperplasia due to unopposed estrogen ■ oral hypoglycemic (e.g. metformin) if type 2 diabetic or if trying to become pregnant
■ tranexamic acid (Cyklokapron®) for menorrhagia only
• infertility
■ medical induction of ovulation: clomiphene citrate, letrozole, human menopausal gonadotropins
(HMG [Pergonal®]), LHRH, recombinant FSH, and metformin
◆ metformin may be used alone or in conjuction with clomiphene citrate for ovulation induction
■ ovarian drilling (perforate the stroma), wedge resection of the ovary
■ bromocriptine (if hyperprolactinemia) • hirsutism
■ any OCP can be used
◆ Diane 35® (cyproterone acetate): antiandrogenic
◆ Yasmin® (drospirenone and ethinyl estradiol): spironolactone analogue (inhibits steroid
receptors)
■ mechanical removal of hair
■ finasteride (5-α reductase inhibitor)
■ flutamide (androgen reuptake inhibitor)
■ spironolactone: androgen receptor inhibitor