1. PCOS Polycystic Ovary Syndrome

2. Objectives Know the clinical definition of PCOS
Know the typical physical and laboratory findings associated with PCOS
Be familiar with the current management options

3. Definition Polycystic ovary syndrome is a clinical diagnosis
2 or more of the following features:
Chronic oligo-ovulation or anovulation
Androgen excess
Polycystic ovaries

4. Epidemiology Affects 5-10% of women of childbearing age
Most common cause of anovulatory infertility in developed countries
Prevalence of the metabolic syndrome is 2-3x higher among women with PCOS

5. Theories to Etiology of PCOS
Genetic predisposition
Most likely although no gene isolated
Premature adrenarche (<8 y/o)
Heterozygosity for congenital adrenal hyperplasia (CAH)
Intrauterine Growth Retardation (IUGR)

6. Pathophysiology
Majority of women with PCOS (regardless of weight), have insulin resistance
Association with: type 2 diabetes, dyslipidemia, and hypertension
Effects of hyperinsulinemia
Ovaries remain sensitive to insulin (maybe hypersensitive)  Androgen excess
Inhibits hepatic production of sex hormone binding globulin  increases circulating free testosterone
Impedes ovulation

7. Nestler J. N Engl J Med 2008;358:47-54

8. Cascade leading to excess androgens

9. CYCLE STARTS
Vicious Cycle of PCOS

10. Clinical Findings Anovulation  amenorrhea & infertility Hirsuitism
Acne Vulgaris
Male pattern baldness/thinning
Obesity- android-type with waist-hip ratios
Cancer- endometrial

11. Evaluation: Differential Dx
MORE LIKELY
LESS LIKELY
Pregnancy
PCO
Hypothyroidism
Ovarian tumor
Pituitary tumor
CAH
Female Athlete Triad (hypothalamic amenorrhea)
Turner’s syndrome
Testicular Feminization

12. Knowing all of this, what laboratory tests would you order for a patient you are suspecting of PCOS?

13. Laboratory Tests to Consider in Evaluation Process
B-HCG
Thyroid
LH/FSH
Prolactin
Free/total testosterone
Fasting 17-OPH and cortisol
Fasting glucose
Fasting Insulin level
Fasting Lipid profile
Androstenedione
DHEAS
Karyotype
RED - those tests most critical to diagnosis of PCOS
GREEN – consider these tests as associated problems with PCOS

14. Ultrasound Findings

15. Problems associated with high levels of sex hormones:
Insulin resistance
Hyperinsulinemia
Diabetes
Cardiovascular disease

16. Management: Non-medical
Weight control
Low carb diets
Exercise
reduce weight and CV risk factors
Increase insulin sensitivity

17. Management: Medical OCP’s: suppress LH  androgens
SHBG  free testosterone
adrenal production of androgen
 5alpha-reductase
Spironolactone
Cyclic progestins
GnRH agonists

18. Management: Metformin
Reduces hyperinsulinemia
Decreases risk factors for CHD
Improved weight-loss
Normalization of circulating androgens
Resumption of normal ovulatory menses and therefore reversal of infertility