Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS)

·        Seek help for: infertility (anovulation), menstrual irregularity and androgen excess

·        Symptoms: oligomenorrhoea, amenorrhoea, anovulation, infertility, hirsutism, acne, male pattern hair loss

·        If rapid viralisation then look for tumour – not PCOS

·        Associated with:

o   Obesity 

o   Type 2 diabetes – insulin resistance ® hyperinsulinaemia

o   Lipid abnormalities ® vascular disease (eg 7 times risk of MI)

·        Pathogenesis:

o   ?Primarily a disorder of LH hypersecretion

o   ­Non-cyclical oestrogen (including from adrenal androgens and obesity) leads to: 

§  ­LH ® ovarian hyperplasia ® ­androgens ® perpetuates the cycle 

§  ¯FH ® ¯follicular maturation ® ¯cyclical oestrogen ® chronic anovulation ® ¯progesterone ® no menses 

o   Hormonal cycling is disrupted and ovaries enlarged by follicles with have failed to rupture

·        Investigations:

o   Serum total testosterone

o   Sex hormone binding globulin

o  LH and FSH.  Testosterone and LH high.

o  Fasting HDL, LDL, cholesterol

o  Glucose tolerance test (if pregnant do at beginning of pregnancy) 

o  Rarely: DHEAS for adrenal androgen tumour + 17-hydroxyprogresterone for congenital adrenal hyperplasia

·        Treatment: 

o  Diet and exercise ® ¯weight ® ¯peripheral oestrogen

o  Induce ovulation with Clomifene ® ­FSH

o  Combined pill (Diane 35) to control bleeding and ¯risks of unopposed oestrogen on endometrium 

o  Metformin ® ­insulin sensitivity, ¯menstrual disturbance and ­ovulatory function

o  Prevention of risks of diabetes and ischaemic heart disease

o  Established facial hair won‟t go away when hormones corrects (require cosmetic treatment)

·        Differential: Tumours of the ovary (eg granulosa and thecal cells) ® chronic anovulation