Polycystic ovarian syndrome PCOS, Stein-Leventhal syndrome
Posted by dkwinter

See also:
     Amenorrhea Ddx


Pathophysiology
     Cause of anovulation is not completely clear but thought to be due to 
          Imbalances in LH and FSH production
          Insulin resistance
Epidemiology
     6.5-20% of women of reproductive age
     Average age 15-35 yo
Hx
     Anovulation (and secondarily infertility)
     50% of PCOS patients are obese
Sx
     Infertility
     Menstrual irregularity
     Signs of androgen excess/hyperandrogenism
          Hirsutism
          Acne
          Male-pattern baldness
     Metabolic disturbance
          Obesity
          Insulin resistence
          Dyslipidemia
          HTN
     Ovarian cysts
Workup
     Fasting blood glucose:insulin ratio insulin <4.5 = insulin resistence
     OGTT (esp if obese)
     Transvaginal u/s
     Urine hCG
     U/S-pelvis
     LH/FSH > 2:1 (highly incr LH) although not part of diagnostic criteria
     TSH, Prolactin
     Free Testosterone (incr) (most sensitive), androstenedione (incr), DHEAS (incr), SHBG (decr)
Complications
     Endometrial hyperplasia
          OCP is preventative
Associated with
     Infertility
     Insulin resistance
     T2DM
     Cardiovascular disease
     Endometrial carcinoma
          Pts usually have adequate estrogens because of androgen conversion to estrogens in peripheral tissues, even in the absence of normal ovarian function. But, women with PCOS are oligoovulatory or anovulatory and therefore progesterone deficient. Thus, constant unbalanced estrogen stimulation of endometrium causing hyperplasia, bleeding and sometimes cancer.
Dx
     PCOS diagnosis includes the presence of any two of the following three signs and symptoms:
          1) Clinical (i.e. hirsutism, acne, or male pattern baldness or "androgenic alopecia") and/or biochemical (i.e. high serum androgen concentrations) hyperandrogenism.
          2) Amenorrhea or oligomenorrhea (irregular menses for 6 mo)
          3) Pelvic ultrasound with cystic ovaries; small cysts are noted around the ovaries in a class "string of pearls" appearance
     A standard 2-hour oral glucose tolerance test (OGTT) identifies most patients with impaired glucose tolerance and early type 2 diabetes better than fasting glucose alone
Ddx
     Late onset congenital adrenal hyperplasia
     Cushing's syndrome
     Ovarian + adrenal neoplasm
     Hyperprolactinemia
Tx
     Cycle control
          Decr peripheral estrogen via decr BMI via incr exercise
          OCP monthly
          Cyclic provera
          Oral hypoglycemia (metformin 500mg TID)
     Infertility      
          Medical induction of ovulation: clomiphene citrate, hMG, LHRH, recombinant FSH 
          Oral hypoglycemia (metformin 500mg TID)
          Ovarian drilling
          Bromocriptine (if hyperprolactinemia)
     Hirsutism
          OCP
          Diane 35 -- anti-androgenic
          Mechanical removal of hair
          Finesteride (5-alpha reductase inhibitor)
          Flutamide (androgen reuptake inhibitor)