Polycystic Ovarian Syndrome

Case-based Presentation

Candice E. Reyes, OMS III

Obstetrics/Gynecology
Arrowhead Regional Medical Center
 HPI
DL is a 25 y/o Caucasian F c/o irregular
periods. Her LMP was 5 mo prior and her
periods have been irregular since
menarche. She notes a 30lb wt gain over
the past 6 mo. She is sexually active w/her
boyfriend and uses condoms for
contraception. She also c/o that she has been
breaking out more on her face and back. In
addition, she confides that she started to wax
the hair on her face and chest because she
was embarrassed of it being dark and thick.
 Subjective
• PMHx: Obesity
• FHx: Mother and Father have Type II DM
• SHx: Pt denies any surgical procedures
• SocHx: Pt is a high school teacher. Pt drinks
socially - 1-2 drinks/wk. Pt denies use of
tobacco products or recreational drugs. She
exercises 30min 2-3x/wk. Pt eats a
moderately healthy diet.
• Meds: Multivitamin
• Allergies: NKDA
 ROS
• General: Pt states a 30lb wt gain
• Skin: Pt states she has “breakouts” on
her back and face. Pt also states that she
has a lot of unwanted hair on her face and chest
• HEENT: Pt denies any changes in vision, hearing, smelling.
Pt denies lesions.
• Neck: Pt denies lymphadenopathy
• Pulm: Pt denies SOB, coughing, wheezing
• CV: Pt denies chest pain, palpitations, sweating
• GI: Pt denies dyspepsia, nausea, vomitting, constipation,
diarrhea
• GU: Pt denies dysuria, polyuria, vaginal pain or itching,
dyspareunia
• Neuromuscular: Pt denies muscle weakness or wasting.
Pt denies syncope, vertigo, or diplopia
 Physical Exam
• Vitals T 98.7 R 16 P 70 BP 126/96 Pain 0 Ht 5’5’’ Wt 248lbs
• Gen: 25 y/o obese WF in NAD
• Skin: moderate acne on face and back, dark hair on chin and chest,
neg acanthosis nigricans
• HEENT: NCAT. Ears clear. Eyes are not icteric and conjunctiva not
injected. PERRLA. Nose clear.
• Neck: Supple, no thyroid enlargement
• Lungs: CTAB
• CV: RRR, neg m/c/r/g
• Abd: obese, NTTP, neg R/G, neg striae
• Pelvic: nml ext female genitalia, neg clitoromegaly, moist epithelium,
and neg lesions on vagina and cervix, on bimmanual - no masses
palpated
• Extremities: pulses 2+ B UE and LE, neg wasting or edema
 Ddx
• Other causes of hyperandrogenism
– Nonclassical congenital adrenal hyperplasia
– Androgen-secreting neoplasms
– Cushing syndrome
– Acromegaly
– Hyperprolactinemia (pituitary adenoma)
– Progestational agents
• Other causes of anovulation
– Extreme exertion
– Rapid weight changes
– Premature ovarian failure
– Hyperthyroidism
– Hypothyroidism
– Eating disorder
 Making the Diagnosis
• 2003 international consensus panel diagnostic
criteria in Rotterdam, Netherlands
– At least 2 of
• Oligo/anovulation (menstrual irregularities)
• Hyperandrogenism
• Polycystic ovaries on Utz
• ACOG Practice Bulletin 108 uses 1990 NIH
consensus panel criteria
– Chronic anovulation
– Clinical or biochemical signs of hyperandrogenism
– Other causes excluded
 Next step
• Urine hCG
– R/o pregnancy
• TSH and prolactin levels
– R/o common endocrine causes for amenhorrhea
– Prolactin is nml to mild elev in PCOS
• Hormone levels - testosterone, LH, and FSH
– LH:FSH ratio is >2:1 and testosterone is nml to
mod elev in PCOS
• Fasting glucose and fasting lipid
– Metabolic considerations
 Results
• Urine hCG
– Negative
• TSH and prolactin levels
– Nml TSH and prolactin
• Hormone levels - testosterone, LH, and FSH
– LH:FSH 3:1 and testosterone is mildly elevated
• Fasting glucose and fasting lipid
– Fasting glucose 115
– LDL 130 Total 210 HDL 45 Trig 145
 Still uncertain?
• Pelvic Utz
– May visualize cysts
• 17-hydroxyprogesterone
– Consider congenital adrenal hyperplasia
• Dexamethasone suppression test
– Consider Cushing’s
• DHEA-S
– Consider adrenal tumors
• Insulin-like GF
– Consider acromegaly
 Treatment
• Weight Reduction
– Lifestyle modifications
– Metformin
• Prevent endometrial hyperplasia (patient does not
want to get pregnant)
– Progestin therapy, e.g. medroxyprogesterone (Provera)
or norethindrone (Norlutin)
– Low-dose OCP
• Advantage - may regulate menstrual cycle and improve
androgenic symptoms (hirsutism, acne)
– GnRH analog luprolide (Lupron) IM depot reserved for
those who cannot tolerate OCPs
• Long term effects - hypoestrogenemia (hot flushes, bone
demineralization, atrophic vaginitis
 Follow-up
DL just got engaged and will be getting
married in a year. She inquires about
her ability to get pregnant. Since
starting the low-dose OCP, she has
had more frequent and regular
periods. In addition, her acne and
hirsutism have nearly resolved.
 What is the treatment now?
• Ovulation induction
– Clomiphene citrate (Clomid)
• Associated with 75% ovulation rates and 30-40% pregnancy rates
– Human menopausal gonadotropins e.g. follitropin alpha
• Associated with 58-82% pregnancy rates, but risk of ovarian
hyperstimulation and multiple pregnancies
– Metformin (Glucophage) improves ovulation and
pregnancy rates
• Surgery
– Wedge resection of ovary not used as commonly now that
OI agents are available
– Ovarian drilling
• Associated with spontaneous restoration of ovulation, subsequent
pregnancy, but postop complications may outweigh benefits
 Risks in Pregnancy
• Miscarriage
• PIH
• GDM
• Premature delivery
Discussion and Questions?
 References
• ACOG Practice Bulletin. Clinical Management
Guidelines for Obstetrician-Gynecologists:
number 41, December 2002. Obstet Gynecol.
2002 Dec;100(6):1389-402.
• Legro, Richard S. Clomiphene, Metformin, or
Both for Infertility in the Polycystic Ovary
Syndrome. N Engl J Med 2007 356: 551-566.
• Revised 2003 consensus on diagnostic
criteria and long-term health risks related to
polycystic ovary syndrome. Fertil Steril. 2004
Jan;81(1):19-25.