POLYCYSTIC OVARY SYNDROME Marte Hoffman MN, ARNP

It helps to know… T is a precursor to Estrogen. Progesterone protects the uterus Estrogen builds the uterine lining; progesterone keeps it glued to the wall The ovarian follicle is lined with theca cells and granulosa cells. They are responsible for the production of T and E.

It helps to know…. You have to rule out “a bunch of stuff” before you can diagnose PCOS There are different kinds of uterine bleeding. Your pts will call all of them “my period.” . A real menstrual period is signaled by falling progesterone. In PCOS, the uterus bleeds because it is too full, not because it got a signal.

It helps to know…. There are lots of hormones discussed in this lecture….. Wave to me when you start to glaze over. 

Symptoms of PCOS Common- No bleeding or irregular bleeding Excess terminal hair Acne Infertility Acanthosis nigricans Obesity (especially truncal) 50% And 50% are not obese

symptoms Less common: Thinning hair Skin tags Abnormal lipids HTN diabetes

Associated features Insulin resistance Obesity Elevated LH:FSH ratio (3:1) Early onset – cycles were never monthly Too much testosterone

HX: things to ask Age of menarche? Have you ever had predictable, monthly periods? Any unwanted body hair? Skin tags? Darkly pigmented skin? Any fe relatives with: irregular periods? bad acne? excess hair growth? infertility? Any FH of type II diabetes? Do your breasts leak?

PE Body size and composition Acanthosis Nigricans (sign of hyper insulin) Skin tags HTN Hair distribution Acne Breasts leaking Facial features Clitoromegaly Pelvic masses

Differential diagnosis Pregnancy Thyroid disorders Pituitary problems Adrenal problem PCOS

Diagnosis 1 Rule out other causes of sx 2 Establish status Metabolic Hormonal 3 Make diagnosis

Diagnosis-rule out other causes Pregnancy Thyroid Pituitary problems Hyperprolactinemia Pituitary tumor

Diagnosis-rule out other causes Adrenal Problems Androgen secreting tumor DHEA-S Adrenal Tumor DHEA-s and testosterone Non classic CAH - 17a hydroxyprogesterone (congenital adrenal hyperplasia) - Cushing’s Syndrome – dexamethasone suppression test

Diagnosis-2 Establish status METABOLIC – FASTING LIPIDS FASTING GLUCOSE Insulin Level Hormonal – FHS, LH - TESTOSTERONE free and total

Diagnosis-3. make diagnosis Any 2 of the following: Chronic anovulation Androgen excess: lab or observation Pelvic Ultrasound shows polycystic ovaries

Part II: physiology and pathophysiology NORMAL CYCLE : (Day 1-5) Ovary is starting to load up with testosterone being mfgd in the theca cells. FSH is starting to climb; tells the ovary time to make estrogen

Physiology NORMAL CYCLE : Day 6-10: Estrogen levels are increasing FSH still climbing; wants more estrogen made

physiology NORMAL CYCLE : Day 11-15: Estrogen levels are still increasing; Estrogen gets high enough to trigger LH surge. LH shoots way up The follicle bursts Egg is released; OVULATION!

physiology NORMAL CYCLE : 2ND HALF (LUTEAL) Day 16-28. THE “POK” WHERE THE EGG WAS, IS CALLED “CORPUS LUTEUM”. For the next 2 weeks, the corpus luteum secretes progesterone. (Helps lining stick to the uterine wall) As corpus luteum “heals”, progesterone level drops, the “velcro” dissolves, the lining slips off. Cycle repeats

physiology Summary Ovary turns testosterone into estrogen Estrogen triggers LH to rise LH triggers Ovulation Ovulation enables production of progesterone Progesterone keeps uterine lining in place Progesterone falls, lining sheds

SHBG – STAYS HIGH Normal cycle SEX HORMONE BINDING GLOBULIN The BIG SPONGE SOPS UP LOTS OF FREE TESTOSTERONE. Free T is low.

PEARL NOT ENOUGH ESTROGEN? NO OVULATION!

PEARL No ovulation? No progesterone!

Pathophysiology PCOS PATTERN For some reason, (probably insulin resistance)… Testosterone doesn’t convert to estrogen (WELL, JUST A LITTLE) Not enough estrogen to trigger an LH surge, but enough to keep a slow build up of the uterine lining.

PCOS NO OVULATION NO PROGESTERONE NO SIGNAL TO SHED LINING -“OVERFLOW” BLEEDING

PCOS SHBG - ALL MESSED UP LEVELS ARE LOW. (LITTLE SPONGE, LOTS OF FREE TESTOSTERONE TO FLOAT AROUND AND GET INTO MISCHIEF LIKE ACNE AND MOUSTACHES)

Part 3 RISKS OF PCOS TYPE II DIABETES CHOLESTEROL PROBLEMS ENDOMETRIAL CANCER INFERTILITY

PCOS MANAGEMENT GOALS: DEPENDS ON PT UTERINE PROTECTION SYMPTOM RELIEF REGULAR CYCLES UTERINE PROTECTION SYMPTOM RELIEF CORRECT INFERTILITY

Quiz True or false 1 LH is a precursor to estrogen T F 2 Which hormone builds up the uterine lining? Which one makes the “velcro”? 3 In PCOS, the trigger to shed the lining is delayed T F

Fun quiz Dark pigmentation of the skin is called: The excess hair of PCOS is thin and fine T / F 50 % of women with PCOS are nl wt T / F 7. What are skin tags a marker of ?

Quiz -knows 8. Which of the following does NOT belong in the differential? Thyroid disorder Pituitary tumors Androgen secreting tumors Dance fever

Quiz – o - Lab 9.Prolactin levels are drawn to rule out….. 10. To rule out androgen secreting tumor, what test do you order?

Oh home on the range 11. Name a classic feature of Cushing’s Syndrome

Whiz Quiz 12. Name 2 of the 3 things you need in order to to diagnose PCOS after you’ve ruled out the other stuff.

Gee Quiz 13. In the normal menstrual cycle, describe the signal that tells the uterus to shed its lining. 14. In PCOS why do women bleed?

The Wizard of Quiz 15. In PCOS, Why are testosterone levels so high? 16 In PCOS is SHBG high or low?

Quiz –o- rama 17 You suspect your patient is not ovulating because: - she only has a period every 4 months - she never craves chocolate - all her kids are adopted - he is male.

Quiz 18 Why are so many women with PCOS put on birth control pills if it is unlikely that they will get pregnant? 19 Why are they given metformin?

Medication quiz THE END!  20 What medication could you use to help control hirsutism? THE END! 