1. PCOS: Polycystic Ovarian Syndrome
NURS 541: Women’s Healthcare – Diagnosis and Management

2. Objectives Etiology Clinical Presentation Assessment Diagnosing PCOS
Management
Patient Counseling

3. Introduction Classified as a hyperandrogenic disorder
Affects 6-8% of women
Approximately 70% of women with clinical features of PCOS have the disorder

4. Etiology Imbalance of several reproductive hormones
Dehydroepiandrosterone sulfate (DHEA-S)
Dehydroepiandrosterone (DHEA)
Androstenedione
Testosterone
Most testosterone is bound to sex hormone-binding globulin (SHBG)
The amount of free testosterone dictates the amount of hyperandrogenic effects that are seen

5. Etiology SHBG free testosterone effects
SHBG levels (and therefore the amount of testosterone binding) are influenced by hormonal changes
Estrogen and thyroid hormone INCREASE levels
Androgens and insulin DECREASE levels
SHBG free testosterone effects
Testosterone converted into dihydrotestosterone (DHT) by 5α reductase (enzyme)
DHT responsible for androgenic symptoms

6. Etiology
Women with PCOS have more steady levels of gonadotropins and sex hormones than women without PCOS
Gonadotropin-releasing hormone (GnRH), and therefore luteinizing hormone (LH) pulse frequently versus with the menstrual cycle
Increased level of LH => decreased follicle-stimulating hormone (FSH)
Decreased ovulation

7. Etiology
Typical cyclical LH surge (below) compared to the frequent LH surges seen in PCOS (left)

8. Etiology
Determining the cause of the increased androgen production is key to individualized treatment
Is it an issue of excess insulin?
Is it an issue of decreased thyroid hormone?
Is there too little estrogen?
Is there too much DHEA/DHEA-S/androstenedione?

9. Clinical Presentation

10. Clinical Presentation
Signs
Associated conditions
Hirsutism
Obesity
Alopecia
Infertility
Acne
Insulin resistance
Menstrual irregularities
Dyslipidemia
Polycystic ovaries
Metabolic syndrome
Virilization
Psychological effects
Cancer risks

11. Signs/Symptoms Hirsutism Alopecia Acne
Excessive hair growth in most androgenic-sensitive areas (face, chin, upper lip, areolae, lower abdomen, inner thighs, perineum)
Alopecia
Androgen-related hair loss, usually frontal/crown region
Acne
Enlargement of sebaceous glands, sebum

12. Signs/Symptoms Menstrual Irregularities Polycystic ovaries
Irregular menses, anovulatory cycles
Possible heavy menses due to persistent endometrial stimulation, endometrial hyperplasia
If normal cycles, may be still anovulatory – lack of premenstrual symptoms indication
Polycystic ovaries
As a result of chronic anovulation
One or more ovaries with 12+ enlarged follicles and/or enlarged ovarian volume over 10mL (2003 ESHRE/ASRM consensus)

13. Signs/Symptoms Virilization
Cluster of symptoms including clitoral hypertrophy, severe hirsutism, deepening of the voice, increased muscle mass, breast atrophy, and male pattern baldness
If rapidly progressing, may indicate less common cause of hyperandrogenism
Ovarian or adrenal tumor
Congenital adrenal hyperplasia
Hyperthecosis

14. Associated conditions
Obesity
Approximately ½ of all women with PCOS are obese
Insulin resistance
Affects 50-70% of women with PCOS
Instrumental in hormonal changes associated with hyperandrogenism
Increases risk for Type 2 Diabetes and glucose intolerance
Dyslipidemia
70% of women with PCOS have at least 1 elevated lipid level

15. Associated conditions
Metabolic syndrome
Cluster of conditions – obesity, insulin resistance, dyslipidemia
Increases risk for CV disease and diabetes
Diagnostic criteria - 3 or more of the following:
Waist circumference ≥ 35 inches
Triglycerides ≥ 150mg/dL
HDL cholesterol ≤ 50 mg/dL
Systolic BP ≥ 130 mmHg and/or diastolic BP ≥ 85 mmHg
Fasting glucose ≥ 100 mg/dL

16. Associated conditions
Infertility
Related to anovulation
More than ½ of women with PCOS are fertile, although may take longer to conceive
Psychological effects
Higher rates of depression, anxiety, binge eating higher for women with PCOS
Cancer risks
3-fold increased risk of endometrial cancer
2-fold increased risk of ovarian cancer

17. Differential Diagnosis

18. Differential Diagnosis
PCOS (80%)
Nonclassical congenital adrenal hyperplasia (2%)
Hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) syndrome (4%)
Androgen-producing tumors (rare) – ovarian or adrenal
Idiopathic hirsutism (5%)
Thyroid disorders, androgenic medication, pregnancy, hyperprolactinemia, Cushing syndrome

19. Assessment

20. Assessment
History
Thorough menstrual history (menarche, menstrual pattern, flow, symptoms)
Pregnancy history (ability to conceive, time to conception)
Symptoms/associated conditions of PCOS, including onset and severity – rapid vs slow onset
Medication history
Family history of associated conditions

21. Assessment Physical Exam
Anthropometric measurements – height, weight, BMI, waist circumference
Blood pressure
Skin examination – look for hirsutism, acne, alopecia
Acanthosis nigricans often seen with insulin resistance
Thyroid exam
Breast exam
Pelvic exam – assess for uterine/ovarian masses

22. Assessment Laboratory testing Mixed evidence re: appropriate testing
Testing should reflect findings in history/exam
Hyperandrogenism and ovulatory dysfunction
TSH, prolactin, fasting lipid profile, 2hr OGTT (ACOG, AEPCOS, 2009)
Hyperandrogenism and regular menstrual cycles
Above, PLUS serum progesterone on day of cycle
Less than 3-4 ng/mL = oligo-ovulatory cycle

23. Assessment Laboratory testing (continued) Imaging/Procedures
Testosterone testing – mixed evidence as to usefulness
If tumor suspected, total testosterone recommended, and refer if > 150 ng/dL (100 ng/dL if menopausal)
17-OHP (hydroxyprogesterone)
If congenital adrenal hyperplasia is suspected
Imaging/Procedures
Pelvic ultrasonography
To identify ovarian cysts and endometrial hyperplasia
Endometrial biopsy – chronic anovulation

24. Diagnosing PCOS

25. Differential Diagnosis
PCOS (80%)
Nonclassical congenital adrenal hyperplasia (2%)
Hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) syndrome (4%)
Androgen-producing tumors (rare) – ovarian or adrenal
Idiopathic hirsutism (5%)
Thyroid disorders, androgenic medication, pregnancy, hyperprolactinemia, Cushing syndrome

26. Diagnosing PCOS Two established criteria:
Rotterdam PCOS Consensus Group (2004)
Two of three of the following:
Oligo- or anovulation
Clinical and/or biochemical signs of hyperandrogenism
Polycystic ovaries
Androgen Excess and Polycystic Ovary Syndrome Society
Hyperandrogenism: hirsutism and/or hyperandrogenemia
Ovarian dysfunction: oligo-anovulation and/or polycystic ovaries
Exclusion of other androgen excess or related disorders

27. Management

28. Management Non-pharmacologic modalities
Lifestyle modification – diet, nutrition, exercise
Mechanical hair removal

29. Management Pharmacologic modalities Combined hormonal contraceptives
Progestin with a non- or low androgenic potential preferred
Desogestrel, norgestimate, drospirenone
Signs/symptoms may be reduced/resolve within 2-12 months
Help protect against endometrial hyperplasia with monthly withdrawal bleeds

30. Management Pharmacologic modalities Progestogens Anti-androgens
To prevent endometrial hyperplasia and cancer
LNG-IUS, progestin-only pills, DMPA, implant
Medroxyprogesterone acetate 5-10mg or 200mg micronized progesterone first 14 days of each month
Anti-androgens
For refractory hirsutism or alopecia
May be teratogenic so need effective contraception

31. Management Pharmacologic management (continued)
Insulin sensitizing agents
Metformin – if impaired glucose tolerance, inability to lose weight with diet and exercise or with those at normal weight
Not recommended for treatment of PCOS symptoms
Also helpful for those with infertility
Topical agent
Eflornithine HCl 13.9% (Vaniqa) – to treat hirsutism

32. When to Refer If diagnosis other than PCOS
If initial treatment not successful
Women with infertility issues (not successful with metformin)
If metabolic syndrome present

33. Patient Counseling
Follow up is necessary due to long-term risks of PCOS
Weight management, nutrition, exercise
Screening and management of BP, lipids, diabetes
Management of menstrual cycle, withdrawal bleeds
Support, encouragement, woman-centered care

34. Questions?