13. Polycystic Ovarian Syndrome Flashcards
Describe pathophysiology of polycystic ovarian syndrome (Figure)
Polycystic Ovarian Syndrome is also called what? (1)
chronic ovarian androgenism
Describe diagnosis: Polycystic Ovarian Syndrome (3)
Rotterdam diagnostic criteria: 2 of 3 required:
- oligomenorrhea/irregular menses for 6 mo
- hyperandrogenism
- clinical evidence - hirsutism or acne
- biochemical evidence - raised free testosterone
- polycystic ovaries on U/S (not appropriate in adolescents)
Describe clinical features: Polycystic Ovarian Syndrome (6)
- average age 15-35 yr at presentation
- in adolescents, wait at least 1-2 yr to make diagnosis as adolescence resembles PCOS
- abnormal/irregular uterine bleeding, hirsutism, infertility, obesity, virilization
- acanthosis nigricans: browning of skin folds in intertriginous zones (indicative of insulin resistance)
- insulin resistance occurs in both lean and obese patients
- family history of DM
Describe goal of investigations in: Polycystic Ovarian Syndrome (1)
identify hyperandrogenism or chronic anovulation and rule out specific pituitary or adrenal disease as the cause
Describe investigations: Polycystic Ovarian Syndrome (5)
-
laboratory
- prolactin, 17-hydroxyprogesterone, free testosterone, DHEA-S, TSH, free T4, androstenedione, SHBG
- LH:FSH >2:1; LH is chronically high with FSH mid-range or low (low sensitivity and specificity)
- increased DHEA-S, androstenedione and free testosterone (most sensitive), decreased SHBG
- transvaginal or transabdominal U/S: polycystic-appearing ovaries (“string of pearls” – 12 or more small follicles 2-9 mm, or increased ovarian volume)
-
tests for insulin resistance or glucose tolerance
- fasting glucose:insulin ratio <4.5 is consistent with insulin resistance (U.S. units)
- 75 g OGTT yearly (particularly if obese)
-
laparoscopy
- not required for diagnosis
- most common to see white, smooth, sclerotic ovaries with a thick capsule; multiple follicular cysts in various stages of atresia; and hyperplastic theca and stroma
- rule out other causes of abnormal bleeding
In the tx of polycystic Ovarian Syndrome, how to tx: cycle control (4)
- lifestyle modification (decrease BMI, increase exercise) to decrease peripheral estrone formation
- OCP monthly or cyclic Provera® to prevent endometrial hyperplasia due to unopposed estrogen
- oral hypoglycemic (e.g. metformin) if type 2 diabetic or if trying to become pregnant
- tranexamic acid (Cyklokapron®) for menorrhagia only
In the tx of polycystic Ovarian Syndrome, how to tx: infertility (3)
- medical induction of ovulation: letrozole, clomiphene citrate (no longer available in Canada), human menopausal gonadotropins (HMG [Pergonal®]), LHRH, recombinant FSH, and metformin
- metformin may be used alone or in conjuction with clomiphene citrate for ovulation induction
- ovarian drilling (perforate the stroma), wedge resection of the ovary
- bromocriptine (if hyperprolactinemia)
In the tx of polycystic Ovarian Syndrome, how to tx: Hirsutism (5)
- any OCP can be used
- Diane 35® (cyproterone acetate): antiandrogenic
- Yasmin® (drospirenone and ethinyl estradiol): spironolactone analogue (inhibits steroid receptors)
- mechanical removal of hair
- finasteride (5-α reductase inhibitor)
- flutamide (androgen reuptake inhibitor)
- spironolactone: androgen receptor inhibitor
Polycystic Ovarian Syndrome may be confused with what? (5)
- Late onset congenital adrenal hyperplasia (21-hydroxylase deficiency)
- Cushing’s syndrome
- Ovarian and adrenal neoplasms
- Hyperprolactinemia
- Hypothyroidism
Name: Clinical Signs of Endocrine Imbalance (6)
- Menstrual disorder/amenorrhea (80%)
- Infertility (74%)
- Hirsutism (69%)
- Obesity (49%)
- Impaired glucose tolerance (35%)
- DM (10%)
Name long-term health consequences of Polycystic Ovarian Syndrome (6)
- Hyperlipidemia
- Adult-onset DM
- Endometrial hyperplasia
- Infertility
- Obesity
- Sleep apnea
