1. POLYCYSTIC OVARY SYNDROME
Marte Hoffman MN, ARNP

2. 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.

3. 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.

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

5. 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

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

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

8. 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?

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

10. Differential diagnosis
Pregnancy
Thyroid disorders
Pituitary problems
Adrenal problem
PCOS

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

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

13. 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

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

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

16. 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

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

18. 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!

19. 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

20. 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

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

22. PEARL
NOT ENOUGH ESTROGEN?
NO OVULATION!

23. PEARL
No ovulation?
No progesterone!

25. 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.

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

28. 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)

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

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

31. 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

32. 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 ?

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

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

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

36. 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.

37. 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?

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

39. 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.

40. 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?

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