1. Polycystic ovarian syndrome PCO
AHMED ABDULWAHAB

2. Polycystic ovary syndrome (PCOS), syndrome, is one of the most, common endocrine disorder among women .
PCOS has a diverse range of causes that are not entirely understood, but there is evidence that it is largely a genetic disease.

3. PCOS produces symptoms in approximately 5% to 10% of women of reproductive age and is thought to be one of the leading causes of female subfertility  and the most frequent endocrine problem in women of reproductive age.
 Finding that the ovaries appear polycystic on ultrasound is common, but it is not an absolute requirement in all definitions of the disorder

4. The most common immediate symptoms are anovulation, excess androgenic hormones, and insulin resistance.
Anovulation results in, irregular menstruation, amenorrhea, and ovulation-related infertility. Hormone imbalance generally causes acne and hirsutism.
Insulin resistance is associated with obesity, type 2 diabetes, and high cholesterol levels.
The symptoms and severity of the syndrome vary greatly among those affected.

5. Signs and symptoms.
Common symptoms of PCOS include the following:
Menstrual disorders:
 oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur,
Infertility
 This generally results directly from chronic anovulation 

6. High levels of masculinizing hormones: The most common signs are acne , hirsutism and  androgenic alopecia .
Metabolic syndrome.
 This appears as a tendency towards central obesity and other symptoms associated with insulin resistance 
Asians affected by PCOS are less likely to develop hirsutism than those of other ethnic backgrounds

7. Cause.
PCOS is a heterogeneous disorder of uncertain cause ,there is strong evidence that it is a genetic disease.
The genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance 

8. Diagnosis.
Not everyone with PCOS has polycystic ovaries (PCO), nor does everyone with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one.
 The diagnosis is straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms.

9. Rotterdam.
 indicated PCOS to be present if any 2 out of 3 criteria are met, in the absence of other entities that might cause these findings oligoovulation and/or anovulation
excess androgen activity
polycystic ovaries (by gynecologic ultrasound)

10. Differential diagnosis.
Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secreting neoplasms , and other pituitary or adrenal disorders, should be investigated

11. Management.
The primary treatments for PCOS include: lifestyle changes, medications and surgery.
Goals of treatment may be considered under four categories:
Lowering of insulin resistance levels
Restoration of fertility
Treatment of hirsutism or acne .
Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer
General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause.

12. Diet.
Where PCOS is associated with overweight or obesity, successful weight loss is the most effective method of restoring normal ovulation/menstruation,
Medications.
Reducing insulin resistance by improving insulin sensitivity through medications such as metformin, and the newer  (glitazones), have been an obvious approach and initial studies seemed to show effectiveness

13. Infertility.
Not all women with PCOS have difficulty becoming pregnant. for those that  anovulation or infrequent ovulation.
For overweight, anovulatory women with PCOS, weight loss and diet adjustments, are associated with resumption of natural ovulation.

14. For those women that after weight loss still are anovulatory or for anovulatory lean women, then the ovulation-inducing medications clomiphene citrate.  and gonadotrophins are the principal treatments used to promote ovulation 
The anti-diabetes medication metformin was recommended treatment for anovulation,  but it appears less effective than clomiphene.

15. Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling“ .
Often results in either resumption of spontaneous ovulations,  or ovulations after adjuvant treatment 

16. Hirsutism and acne.
When appropriate (e.g., in women of child- bearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism .
Other drugs with anti-androgen effects include flutamide,[and spironolactone .
. Metformin can reduce hirsutism, perhaps by reducing insulin resistance.
 5-alpha reductase inhibitors (such as finasteride and dutasteride) may also be used,  they work by blocking the conversion of testosterone to dihydrotestosterone  

17. Menstrual irregularity and endometrial hyperplasia.
If fertility is not the primary aim, then menstruation can usually be regulated with an oral combined contraceptive pills.
 If menstruation occurs less often or not at all, some form of progestogen replacement is recommended,

18. Prognosis.
A diagnosis of PCOS suggests an increased risk of:
Endometrial hyperplasia and endometrial cancer 
Insulin resistance/Type II diabetes., particularly if obese, they are prone to gestational diabetes.
High blood pressure, in particular if obese and/or during pregnancy
Depression/Depression with Anxiety.
Dyslipidemia .
Cardiovascular disease.
Miscarriage.
Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck)]
The risk of ovarian cancer and breast cancer is not significantly increased overall.