Polycystic Ovary Syndrome

PCOS Cathy Eichler, PGY-1 Resident

The set of symptoms related to hormonal imbalance that predominantly affects

women of reproductive age but increase the risk for other comorbidities that can
continue after menses end.

Etiology Epidemiology
Exact causation is unclear, but a combination of genetic Incidence: 6-12% of US
and environmental factors play a role in the women of reproductive age
development of PCOS One of most common causes
of female infertility
Pathophysiology: the ovaries produce an above
normal level of androgens and may also make a below
normal level of estrogen Increased risk of:
Metabolic syndrome
Can range from asymptomatic to a Type 2 Diabetes risk
PRESENTATION combination of manifestations Cardiovascular disease
Gynecologic: Dermatologic: Metabolic: Obesity



Mood disorders
Infertility Excess hair growth Obesity Obstructive sleep apnea
Amenorrhea Severe, late-onset, Weight gain or Endometrial hyperplasia
Oligomenorrhea or persistent acne trouble losing
Very heavy periods Oily skin weight
Bleeding, but no Acanthosis nigricans Insulin resistance
ovulation
Pelvic pain

DIAGNOSIS Combination of inclusion characteristics

and exclusion of other causes
Rotterdam Criteria
Two of three of the
following:
-Hyperandrogenism
-Ovulatory dysfunction
-Polycystic ovaries
-If low body weight, eating disorder, or
excessive exercise, rule out hypothalamic
amenorrhea
Measure TSH, 17-OHP,
-If hot flashes and urogenital symptom, rule
and prolactin to rule out
out primary ovarian insufficiency
thyroid dysfunction,
-If severe virilization, rule out androgen-
pregnancy,
secreting tumor
hyperprolactinemia, and
non-congenital adrenal
-If presence of buffalo hump, purple striae,
or hypertension, rule out Cushing syndrome
hyperplasia
-If change in hat or glove size, protruding jaw
or impaired vision, rule out acromegaly
 No cure, Goals: regulate menstruation, address symptoms, resolve infertility, and
TREATMENT reduce risk of complications

Screening: Weight Reduction:

Can reduce insulin resistance and improve ovulation
Metabolic symptoms: Even a 5% weight loss has been shown to improve
Evaluate blood pressure, lipid PCOS symptoms
panel, two-hour oral glucose Lifestyle Modifications:

tolerance test 500-750 kcal/day deficit

Overweight: Diet low in dairy and carbohydrates
Evaluate for obstructive sleep 150 mins of moderate activity per week or 75 mins of
apnea vigorous activity per week
All patients should be Acupuncture, stress management
screened for depression Supplements like cinnamon and black cohost, and

inositols in foods like fruits and beans

Pharmacologic: individualized to patients presenting symptoms and desire for conception

Desire for

No Desire for Conception
Conception

First line:
gonadotropins,
Anovulation clomiphene or First line: hormonal contraception (including
or infertility letrozole Mirena)
Second line:
metformin

Insulin
Metformin Metformin
resistance

Obesity Lifestyle modification Lifestyle modifications

First line: hormonal contraception with/without

antiandrogen therapy
Electrolysis and light-
Second line: spironolactone, electrolysis, light-
Hirsutism based therapies (mild
based therapies, eflornithine (Vaniga), finasteride
cases)
(Proscar)
Third line: metformin

Topical creams First line: hormonal contraception, topical creams

Acne (antibiotics, benzoyl (benzoyl peroxide, tretinoin, adapalene, antibiotic)
peroxide, etc.) Second line: spironolactone
Test Your Knowledge

A 28-year-old female patient who has always struggled with painful cystic acne
and weight fluctuation recently stopped her oral contraception to begin trying to
conceive. However, it has been 6 months and she has not received a positive
pregnancy test or regained a regular menstrual cycle.
oWhat questions would you want to ask the patient?
oDoes she fulfill the first step in diagnosis of PCOS?

A 32-year-old patient diagnosed with PCOS would like to start trying to conceive.
Until this point, she has been using oral hormonal contraception and adapalene
gel to control her hormonal acne. What should you counsel the patient on
adjusting her skin care regimen?

You are completing an initial diabetes visit with a 36 year old female with a history
of PCOS, HTN, and a BMI of 32 that was recently diagnosed with type 2 diabetes.
When you are discussing lifestyle modifications, what additional counseling or
recommendations would you share with the patient because of her PCOS
diagnosis?

References:

Williams T, Mortada R, Porter S. Diagnosis and Treatment of Polycystic Ovary Syndrome. Am Fam Physician. 2016;94(2):106-113

Bartelme KM, Borgelt LM, Mondiello T, Cho V. Polycystic ovary syndrome. ACSAP 2021 Book 2.

NICHD – Eunice Kennedy Shriver National Institute of Child Health and Human Development. Polycystic Ovary Syndrome (PCOS). Accessed
August 28, 2022. https://www.nichd.nih.gov/health/topics/factsheets/pcos#

NICHD – Eunice Kennedy Shriver National Institute of Child Health and Human Development. Treatments to Relieve Symptoms of PCOS.
Accessed August 28, 2022. https://www.nichd.nih.gov/health/topics/pcos/conditioninfo/treatments/relieve

Szczuko M, Kikut J, Szczuko U, Szydłowska I, Nawrocka-Rutkowska J, Ziętek M, Verbanac D, Saso L. Nutrition Strategy and Life Style in Polycystic
Ovary Syndrome-Narrative Review. Nutrients. 2021 Jul 18;13(7):2452. doi: 10.3390/nu13072452.