Polycystic ovary syndrome

Prof. Basima Sh. Al Ghazali

PCOS is a syndrome of ovarian dysfunction along with the
cardinal features of hyperandrogenism and polycystic ovary
morphology

The prevalence of polycystic ovaries seen on ultrasound is

around 25% of all women but is not always associated with
the full syndrome.
• The aetiology of PCOS is not completely clear,

• although the frequent familial trend points to a

genetic cause.

• combination of genetic abnormalities combined

with environmental factors, such as nutrition and
bodyweight, which then affect expression of the
syndrome
 Clinical manifestations
• menstrual irregularities,
• signs of androgen excess (e.g. hirsutism and acne)
• and obesity.
• Elevated serum LH levels, biochemical evidence of
hyperandrogenism and raised insulin resistance are also
common features.
• PCOS is associated with an increased risk of type 2
diabetes and cardiovascular events.

It affects around 5–10% of women of reproductive age.

Acanthosis negricans
Possible late sequelae

 Diabetes mellitus ( hyper insulinemia , impered CHO metabolism )

 Dyslipidemia (insulin resistant , central obesity, hyperandrogenemia)
 Hypertension, cardiovascular disease ( obesity metabolic
abnormality,)

 Endometrial carcinoma ( obesity, un appose estrogen )

 Ovarian cancer ( ?? conflicting study result )
 Serum endocrinology

• ↑ Fasting insulin (not routinely measured)

• ↑ insulin resistance or impaired glucose
• assessed by GTT)
↑ Androgens (testosterone and androstenedione)
•
↑ or normal LH, normal FSH
•
↓ SHBG, results in elevated free androgen index
•
↑ Estradiol, estrone (neither measured routinely as very
• wide range of values)
•
↑ Prolactin
 Management

: Principals of management

• Confirm diagnosis and identify category.

• Identify and manage concurrent illness.
• Identify and manage patient needs.

There are numerous options for successful PCO

management – medical / surgical
SIGNS AND SYMPTOMS OF POLYCYSTIC OVARY
SYNDROME
 Clinical features
• Oligomenorrhoea/amenorrhoea in up to 75% of patients,
predominantly related to chronic anovulation.

• Hirsutism up to 50- 70% of cases.

• Subfertility in up to 75% of women.

• Obesity in at least 40% of patients.

• Acanthosis nigricans (areas of increased velvety skin pigmentation

occur in the axillae and other flexures).

• May be asymptomatic.
 Diagnosis
Patients must have two out of the three features below:

• Amenorrhoea/oligomenorrhoea.

• Clinical or biochemical hyperandrogenism.

• Polycystic ovaries on ultrasound. The morphology of the polycystic ovary has

been re defined as
• An ovary with 12 or more follicles measuring 2–9 mm in diameter and/or
( 19 – 25 ) ??? ( with new high resolution U/S )
• Increased ovarian volume (>10 cm3)
Rotterdam criteria 2003

While these findings support a diagnosis of PCOS, they are not by themselves
sufficient to identify the syndrome.
 Management

Management of PCOS involves the following:

• Combined oral contraceptive pill (COCP) to regulate menstruation. This also

increases sex hormone binding globulin, which will help reduce androgenic
symptoms.
• Cyclical oral progesterone: used to regulate a withdrawal bleed.

• Clomiphene: this can be used to induce ovulation where subfertility is a

factor.

• Lifestyle advice: dietary modification and exercise is appropriate in these

patients as they are at an increased risk of developing diabetes and
cardiovascular disease later in life. Aerobic exercise has been shown to
improve insulin resistance.
• Weight reduction.
• Ovarian drilling, a laparoscopic procedure to destroy some of the ovarian
stroma that may prompt ovulatory cycles.

• Treatment of hirsutism/androgenic symptoms: eflornithine cream

(Vaniqua™) applied topically; cyproterone acetate (an antiandrogen
contained in the Dianette™ contraceptive pill, sometimes used alone);

• metformin: this is beneficial in a subset of patients with PCOS, those with

hyperinsulinaemia and cardiovascular risk factors. It improves parameters
of insulin resistance, hyperandrogenaemia, anovulation and acne in PCOS,
and may aid weight loss. It is less effective than clomiphene for ovulation
induction and does not improve pregnancy outcome;

• GnRH analogues with low-dose HRT: this regime should be reserved for
women intolerant of other therapies;

surgical treatments (e.g. laser or electrolysis •(

 References

GYNAECOLOGY / 20th EDITION by Ten Teachers /

CHAPTER 3 / Hormonal control of the menstrual
cycle and hormonal disorders /HELEN BICKER STAFF

Dewhurts textbook of OBSTETRICS & GYNECOLOGY

Ninth Edition 2018 / Chapter ( 47 & 51)