POLYCYSTIC OVARIAN SYNDROME

- Syndrome consisting of amenorrhea, hirsutism, and

obesity in association with enlarged polycystic ovaries
–T he most common hormonal disorder in reproductive-
aged women.
- “classic” features occur in 3% to 7% of the population
but broadest definition may occur in 15% to 20% of
women

ROTTERDAM CRITERIA
Presence of 2 out of 3
Hyperandrogenism
-Acne, Androgenic alopecia, Hirsutism
(Testosterone, Dehydroepiandrosterone)
Ovulatory dysfunction
-Oligomenorrhea, Amenorrhea
Polycystic Ovary
-26 follicles, 2-8mm, or ovary volume >10mL
COMMON COMORBIDITIES
- Metabolic syndrome
- 1/2 are Obese
- Increased risk for Cardiovascular disease
- 4-fold increase in risk of T2DM
- Increased prevalence of NAFLD, Sleep apnea,
dyslipidemia
- Mood Disorders

Recommendations for suspected patients:

- BP every visit
- Lipid levels
- Screening for T2DM
- Repeat T2DM Screening every 2-3 years

PATHOPHYSIOLOGY
- Altered LH action, insulin resistance, possible
predisposition to hyperandrogenism
- Insulin resistance exacerbates hyperandrogenism by:
--suppressing synthesis of sex hormone-binding globulin
--increasing adrenal and ovarian synthesis of androgens
--thereby increasing androgen levels
- These androgens lead to irregular menses and physical
manifestations of hyperandrogenism
PCOS in adolescence
- Anovulation common in menarche, work-up for PCOS
delayed for 2 years since onset of oligomenorrhea
- Must meet all 3 in ROTTERDAM CRITERIA before
diagnosis and work-up
TREATMENT
-Individualized based on patient’s presentation and
desire for pregnancy
Anovulation and infertility
- Lifestyle modification and weight reduction reduce
insulin resistance and significantly improve ovulation
- Lifestyle modification considered first-line therapy for
women who are overweight
Clomiphene – Selective Estrogen Receptor Modulator
(SERM)
- Triggers the pituitary gland to secrete an increased
amount of FSH and LH luteinizing hormone. This action
stimulates the growth of the ovarian follicle and thus
initiates ovulation
Letrozole – Aromatase inhibitor, Antiestrogen
- stops androgens from being converted into estrogen.
Deceased estrogen  pituitary produces more FSH
- Recent studies show that Letrozole is associated with
higher live-birth rates and ovulation compared to
clomiphene
-Metformin – Controversial
Some studies show it confers no additional benefit

Irregular menses
- If not seeking pregnancy, Hormonal Contraception is
initial medication for both irregular menses and
hyperandrogenism manifesting as acne and hirsutism
- No superiority in different classes of Oral
Contraceptives in treating PCOS
-Metformin – Controversial
Studies have shown metformin can restore regular
menses but Oral Contraceptives are superior

Hirsutism
- Oral contraceptives most effective first-line therapy
for mild hirsutism
- Spironolactone – Aldosterone Receptor Antagonist,
Potassium Sparing Diuretic
Spironolactone, in daily doses of 50-200 mg, blocks
androgen receptors. Spironolactone also decreases
testosterone production, making it additionally effective
for hirsutism.
- Flutamide – Anti-androgen, Androgen Receptor
Antagonist
Effectiveness is minimal

Acne
- Hormonal Contraceptives first line + Topical Acne
Therapy (Retinoids, Antibiotics, Benzoyl Peroxide)
- Anti androgens, Spironolactone can be added