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)
