1. Polycystic Ovary Syndrome Krishna B. Singh, MD Department of Obstetrics & Gynecology LSU Health Sciences Center Shreveport, LA

2. PCOS: Learning Objectives After viewing this slide show, you’ll be able to understand that... -PCOS is a common endocrine disorder -Multifactorial, heterogeneous condition -Clinical manifestations affect menses, fertility -Multiple hormonal, biochemical changes -Long-term implications are important

3. PCO Syndrome: Topics Historical review Incidence Clinical features Diagnosis Management Summary

4. PCOS: Literature Review Sclerocystic ovaries were described by Chereau (1844); Pozzi (1894); Waldo (1895) Stein/Leventhal first described seven cases of infertility associated with enlarged polycystic ovaries (1935) The NIH Consensus Conference (1990) The Rotterdam PCOS Consensus Group (2003)

5. Incidence: PCO Syndrome The incidence varies: 5-10% (~5% USA) About 25% normal women may have PCO by ultrasound criteria (BMJ 1986) Ultrasound findings don’t correlate with serum hormone levels

6. Features of PCO Syndrome Symptoms present since puberty: Cyclic menses with luteal-phase progesterone deficiency; hirsutism; hyperandrogenemia; infertility; chronic anovulation/miscarriages Irregular menses in 25-75% women Obesity (60%); also non-obese women Hirsutism and/or acne (virilization rare)

7. Polycystic Ovarian Disease PCO disease can be seen in women with pituitary neoplasms, hypo- or hyperthyroidism, diabetes, adrenal and pelvic neoplasms Rule out PCOD to diagnose PCO syndrome Long-term care is important. Studies have shown increased incidence of hypertension, hyperlipidemia and diabetes. Risk for CVD increased

8. PCO Syndrome: Facts/correlates Genetic factors: autosomal or X-linked Positive correlations of androgen and insulin levels in some studies Ultrasound findings don’t correlate with serum hormone levels

9. Theories of PCO Syndrome PCO syndrome is a multifactorial disorder Theories are based on data in selected women Brain and limbic system control the hypothalamus- pituitary-ovarian axis needed for reproductive cycle initiation and maintenance Feedback CNS abnormality results in PCOS

10. CNS theories of PCO Beta-endorphin theory: Higher plasma levels are found in women with PCO syndrome Progesterone deficiency/estrogen excess is the key component Hyperandrogenism also important in PCO women Hyperprolactinemia may cause breast symptoms, diminish libido, and alter moods in some women

11. More PCO Theories... Rat PCO model: Persistent-estrus syndrome Constant-light exposure; androgenized rat model; hypothalamic lesions Other methods (DHEAS model) Monkey model: testosterone injections Human model: transvestites given androgens

12. Diagnosis of PCO Syndrome History and physical examination important; selected laboratory and hormonal tests during several visits are needed for confirmation Both structured and descriptive notes are evaluated by the physician Follow-up visits arranged @ regular intervals

13. PCOS: Differential Diagnosis Laboratory tests for confirmation: LH/FSH, T Baseline values: Chem-22 @ morning Baseline serum hormones @ morning Pelvic ultrasound in some cases required Consider PCOD versus PCO syndrome

14. PCOS: Key to Diagnosis Rule out conditions which may require referral; focus on the presenting signs and symptoms Beware of misdiagnosis “on the fly” Beware of differential diagnosis History and physical exam; selected tests Know when to refer patients and where

15. PCOS: Management Options Principal components: Confirm diagnosis and identify category; identify and manage concurrent illness; identify and manage patient needs There are numerous options for successful PCO management

16. PCOS: Treatment Options General measures: diet, exercise, relaxation for stress management Contraception: OCP; DMPA Hormones/drugs: Provera; Parlodel; Clomiphene; hMG/hCG; IVF in selected women Newer drugs for treatment of obesity, hyperinsulinemia, hyperandogenemia and hirsutism

17. PCO Syndrome and Infertility About 60% PCO patients will have ovulatory cycles and pregnancy on clomiphene alone About 50% PCO patients will respond to the combined clomiphene and dexamethasone within six months of treatment

18. PCO Syndrome: Summary PCO syndrome remains an enigma despite many scientific studies done during the last three decades Theories of PCO abound; terminology used may be confusing and definitions are not standardized There are many treatment options

19. What This Means... Polycystic ovary syndrome is a common disorder among reproductive age group of women; these women generally have irregular menstrual cycles PCO has many facets of clinical presentation PCO can be successfully managed and treated by conventional means