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Polycystic Ovary Syndrome

PCO

Polycystic ovary syndrome (PCOS) is a common endocrine system disorder among the females of reproductive age.


Presentation

The clinical features of polycystic ovary syndrome include the following [4].

  • Menstrual disorders: Patients with polycystic ovary syndrome usually present with oligomenorrhea or amenorrhea. The irregularities usually appear around the time of menarche.
  • Infertility: This usually results from anovulation. In addition, the risk of recurrent miscarriages is also up to 50 to 60% higher in these women.
  • Metabolic disorder: At least 40% of the women presenting with polycystic ovary syndrome are obese. Central obesity is associated with other symptoms like insulin resistance [5].
  • Hirsutism and acne: High levels of masculinizing hormones in women with polycystic ovary syndrome result in the common signs of acne and hirsutism. Other signs include androgenic alopecia and acanthosis nigricans.
  • Sometimes, the disease may be asymptomatic.
Deepening of Voice
  • […] of voice and increased muscle mass Persistent acne and oily skin ( seborrhoea ) Hidradenitis suppurativa (acne inversa), an inflammatory condition that results in boil-like lumps in the armpits, groin and under the breasts Acanthosis nigricans : dark[dermnetnz.org]
Weight Gain
  • Treatment options for Ms R, including those that may affect her weight gain, are reviewed and implications for future fertility are discussed.[ncbi.nlm.nih.gov]
  • Increased levels of insulin can also cause weight gain which is typically associated with the development of both type 2 diabetes and PCOS.[diabetes.co.uk]
  • Below you will find information on the influence of weight on PCOS symptoms, the benefits of preventing weight gain and different ways to manage weight loss.[jeanhailes.org.au]
Virilization
  • Typically, high androgen levels are associated with increased virilization.[ncbi.nlm.nih.gov]
  • Diagnosis is by pregnancy testing, hormone measurement, and imaging to exclude a virilizing tumor. Treatment is symptomatic. Polycystic ovary syndrome (PCOS) occurs in 5 to 10% of women. In the US, it is the most common cause of infertility.[msdmanuals.com]
  • Thus, the excess of adipose tissue in obese women results in the increased production of both androgens (responsible for hirsutism, acne and virilization) and estrogens.[symptoma.com]
  • In particular, a virilizing tumor should be suspected when hirsutism is rapidly progressive.[aafp.org]
Pelvic Mass
  • However, it is indicated if clinical findings are suggestive of a virilizing tumor (eg, rapid progression, clitoromegaly, pelvic mass, or a total testosterone level 200 ng/dL) or disorder of sex development.[pediatrics.aappublications.org]
Hypertension
  • PCOS was related to hypertensive disorders in pregnancy with a relative risk (RR) of 1.62 (95% CI 1.09-2.42).[ncbi.nlm.nih.gov]
  • These findings may provide a new basis for a proper choice of the antihypertensive drug in hypertensive women with polycystic ovary syndrome.[ncbi.nlm.nih.gov]
  • The first patient had hyperandrogenic, insulin-resistant acanthosis nigricans syndrome and had been resistant to multiple courses of clomiphene citrate; the second exhibited hypertension, hyperlipidemia and glucose intolerance along with anovulation;[ncbi.nlm.nih.gov]
  • Furthermore, there was a direct association between FAI levels and frequency of glucose intolerance (OR 2.480, 95% CI 1.387-4.434), even after adjusting for age, BMI, waist circumference, hypertension, fasting insulin, testosterone, SHBG, and family history[ncbi.nlm.nih.gov]
  • Women with PCOS and insulin resistance have an increased risk of developing many of the consequences of the dysmetabolic syndrome, including type 2 diabetes, hypertension, and hyperlipidemia.[ncbi.nlm.nih.gov]
Hirsutism
  • Hirsutism often occurs in women with polycystic ovary syndrome (PCOS).[ncbi.nlm.nih.gov]
  • Hirsutism and Acne Efornithine cream applied topically reduces hirsutism and acne. Cryproterone acetate is an anti-androgenic contraceptive pill that may also be helpful in the reduction of acne and hirsutism.[symptoma.com]
  • We report the case of an obese 18-year-old Caucasian women with hirsutism and oligomenorrhea. Abdominal palpation revealed a voluminous firm mass. Hormonal evaluation documented severe hyperandrogenism.[ncbi.nlm.nih.gov]
  • Long-term use of COCs (6-12 months) was more effective in improving hirsutism, compared to short term. COCs containing cyproterone acetate (CPA) for 12 months had the strongest effect in improving hirsutism.[ncbi.nlm.nih.gov]
  • A 65-year-old woman presented with elevated testosterone levels, hirsutism and insulin resistance.[ncbi.nlm.nih.gov]
Alopecia
  • Logistic regression analysis showed that there were significant associations between sexual function score and the literacy, alopecia, and infertility.[ncbi.nlm.nih.gov]
  • There was no difference in the prevalence of acne, alopecia, a-/ or oligomenorrhea or PCO-morphology in the two patient groups. Patients with PCOS and AIT were more obese by 2 kg/m² BMI on average.[ncbi.nlm.nih.gov]
  • Balding, also called androgenic alopecia refers to the loss or thinning of scalp hair. Hirsutism, acne or androgenic alopecia can be the result of increased production of male hormone, called androgens, in women with PCOS.[cedars-sinai.edu]
  • Other signs include androgenic alopecia and acanthosis nigricans. Sometimes, the disease may be asymptomatic.[symptoma.com]
  • Hair loss (alopecia) For some women with PCOS, the high level of androgens causes hair loss or thinning of the scalp hair in a 'male-like' pattern: a receding frontal hair line and thinning on top of the scalp.[jeanhailes.org.au]
Acne Vulgaris
  • Hidradenitis suppurativa, like acne vulgaris, may be a feature of hyperandrogenism. Obesity may be associated with both hidradenitis suppurativa and PCOS. We describe a possible association between PASH syndrome and PCOS.[ncbi.nlm.nih.gov]
  • Moderate-severe inflammatory acne vulgaris unresponsive to topical medications is an indication to test for hyperandrogenemia.[pediatrics.aappublications.org]
Hypertrichosis
  • J Clin Endocrin Metab . 2008;93:1105–1120. 35 Hirsutism must be distinguished from hypertrichosis, which is defined as generalized excessive vellus hair growth distributed in a nonsexual pattern, for example, predominantly on forearms or lower legs.[pediatrics.aappublications.org]
Hand Tremor
  • A 21-year-old female patient visited us with complaints of oligomenorrhea and hand tremor. She was diagnosed as having PCOS and hyperthyroid Graves' disease, simultaneously.[ncbi.nlm.nih.gov]
Papilledema
  • Ophthalmologically there was a recurrent papilledema. Clinical neurologic investigations revealed sore neck muscles and hirsutism.[ncbi.nlm.nih.gov]
Amenorrhea
  • A 20-year-old nulligravid woman had been suffering from oligomenorrhea, amenorrhea, and moderate hirsutism since the age of 18 years.[ncbi.nlm.nih.gov]
  • Genital tuberculosis is elusive in presentation and clinicians should consider it in patients with amenorrhea and/or tubal disease from tuberculosis-endemic regions.[ncbi.nlm.nih.gov]
  • Described are the etiology and possible symptoms of PCOS such as amenorrhea/oligomenorrhea, hirsutism, obesity, infertility, persistent acne, ovarian cysts, elevated triglycerides, and adult-onset diabetes, along with possible pathological interference[ncbi.nlm.nih.gov]
  • […] insulin secretion, and positive autoantibodies for GAD-65 and IA-2; (2) autoimmune thyroiditis, with hypothyroidism, positive anti-microsomal and antithyroglobulin antibodies; and (3) PCOS, with hyperandrogenic signs that had developed 5 years earlier, amenorrhea[ncbi.nlm.nih.gov]
  • During therapy, amenorrhea and hirsutism developed, as well as biochemical evidence of hyperandrogenemia and insulin resistance, as assessed by homeostasis model assessment of insulin resistance.[ncbi.nlm.nih.gov]
Oligomenorrhea
  • We report the case of an obese 18-year-old Caucasian women with hirsutism and oligomenorrhea. Abdominal palpation revealed a voluminous firm mass. Hormonal evaluation documented severe hyperandrogenism.[ncbi.nlm.nih.gov]
  • By 11.3 years, oligomenorrhea, androgen excess, and DM2 had appeared.[ncbi.nlm.nih.gov]
  • Described are the etiology and possible symptoms of PCOS such as amenorrhea/oligomenorrhea, hirsutism, obesity, infertility, persistent acne, ovarian cysts, elevated triglycerides, and adult-onset diabetes, along with possible pathological interference[ncbi.nlm.nih.gov]
  • A 21-year-old female patient visited us with complaints of oligomenorrhea and hand tremor. She was diagnosed as having PCOS and hyperthyroid Graves' disease, simultaneously.[ncbi.nlm.nih.gov]
  • Given the presence of bilateral polycystic ovaries, oligomenorrhea and hirsutism. PCOS was suspected, but a normal LH/FSH ratio as measured by RIA led to diagnostic problems.[ncbi.nlm.nih.gov]
Secondary Amenorrhea
  • Here, we present a case of ACTH-dependent pituitary macroadenoma (Cushing's disease) resulting in secondary amenorrhea mimicking polycystic ovary syndrome (PCOS).[ncbi.nlm.nih.gov]
  • Patient 4 had prepubertal overgrowth that evolved into pseudo-acromegaly, insulin resistance, secondary amenorrhea, and androgen excess at 15.6 years.[ncbi.nlm.nih.gov]
  • Symptoms of PCOS include changes in the menstrual cycle, such as: Not getting a period after you have had one or more normal ones during puberty ( secondary amenorrhea ) Irregular periods that may come and go, and be very light to very heavy Other symptoms[nlm.nih.gov]
  • Menstrual disturbances can include delay of normal menstruation (primary amenorrhea ), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea ).[medicinenet.com]
Primary Amenorrhea
  • Menstrual disturbances can include delay of normal menstruation (primary amenorrhea ), the presence of fewer than normal menstrual periods (oligomenorrhea), or the absence of menstruation for more than three months (secondary amenorrhea ).[medicinenet.com]
  • Primary amenorrhea should be evaluated when recognized. The practitioner should also recognize that menstrual abnormalities may not be the chief complaint.[pediatrics.aappublications.org]
Clitoromegaly
  • […] hair growth primarily on the face, back, chest, lower abdomen, and inner thighs [6] Virilization - development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass, and clitoromegaly[physio-pedia.com]
  • A thorough diagnosis is important, especially if your levels of testosterone are above a certain level, or you have symptoms of "virilization" such as facial beard, clitoromegaly (enlarged clitoris), balding at the temples, deepening voice or muscle enlargement[healthywomen.org]
  • In women with rapid symptom onset or significant virilization, such as deepening voice or clitoromegaly, an androgen-secreting tumor should be ruled out.[aafp.org]
  • However, it is indicated if clinical findings are suggestive of a virilizing tumor (eg, rapid progression, clitoromegaly, pelvic mass, or a total testosterone level 200 ng/dL) or disorder of sex development.[pediatrics.aappublications.org]

Workup

The diagnosis of polycystic ovary syndrome is based on history, general physical examination, laboratory investigations and radiographic studies [6].

On history and examination, there are certain obvious findings such as menstrual irregularities, obesity, acne, hirsutism and subfertility.

The patients must have two out of three features given below:

  1. Amenorrhea/oligomenorrhea
  2. Clinical or biochemical hyperandrogenism
  3. Polycystic ovaries on ultrasound

A transvaginal ultrasound is main diagnostic tool to establish diagnosis of polycystic ovaries. The criteria for the definite diagnosis are eight or more subcapsular follicular cysts less than 10mm in diameter and increased ovarian stroma. The follicles may be oriented in periphery giving the appearance of a “string of pearls”.

Laparoscopic examination may also reveal a thickened, smooth, pearl-white outer surface of ovary.

Laboratory testing includes high serum levels of androgens including testosterone. The ratio of lutenizing hormone to follicle stimulating hormone is also elevated in women with polycystic ovary syndrome.

Insulin Increased
  • PCOS is seriously underdiagnosed Emma Kapotes/Rd.com About 7 million U.S. women have polycystic ovary syndrome (PCOS), which results when excess insulin increases the production of androgens (male hormones).[rd.com]
  • When cells can’t use insulin properly, the body’s demand for insulin increases. The pancreas makes more insulin to compensate. Extra insulin triggers the ovaries to produce more male hormones. Obesity is a major cause of insulin resistance.[healthline.com]
Androgens Increased
  • When the ovaries don't produce the hormones needed for ovulation and proper function of the menstrual cycle, the ovaries become enlarged and develop many small cysts which produce androgens.[stanfordchildrens.org]
Liver Biopsy
  • Liver biopsy findings were consistent with severe nonalcoholic steatohepatitis.[ncbi.nlm.nih.gov]

Treatment

Medical management of polycystic ovary syndrome has the following four goals [7].

Diet

Since polycystic ovary syndrome is associated with obesity, a significant reduction in weight is the most effective method in restoring ovulation and normal menstrual cycles. A high carbohydrate diet which can be obtained from fruits, vegetables and whole grain sources may be helpful. Moreover, treatment with essential vitamins (particularly vitamin D) and micronutrients may also be indicated.

Medications

A number of drugs which are helpful in the management of polycystic ovary syndrome are listed below.

  • Combined oral contraceptive pills (COCP): They are helpful in regulating menstruation.
  • Cyclical oral progesterone: They are also used for the regulation of menstruation.
  • Clomiphene: This can be used to induce ovulation when subfertility is present [8].
  • Metformin: This is beneficial in a subset of patients with polycystic ovary syndrome that have hyperinsulinemia and cardiovascular risk factors. It is less effective than clomiphene for ovulation induction and it does not improve pregnancy outcome [9] [10]. It should be discontinued when pregnancy is detected.

Hirsutism and Acne

  • Efornithine cream applied topically reduces hirsutism and acne.
  • Cryproterone acetate is an anti-androgenic contraceptive pill that may also be helpful in the reduction of acne and hirsutism.
  • Metformin improves parameters of insulin resistance, hyperandrogenism, anovulation and acne in polycystic ovary syndrome.
  • GnRH analogues with low-dose hormone replacement therapy should be reserved for women that are intolerant to other therapies.
  • Surgical treatments such as laser or electrolysis may also be considered when other treatments fail to provide a good response.

Prognosis

Women with polycystic ovary syndrome are at an increased risk for endometrial hyperplasia, endometrial carcinoma, miscarriages, strokes, autoimmune thyroiditis and cardiovascular events. However, no known association with breast or ovarian cancer has yet been found.

Early diagnosis and treatment may reduce the risk of some of these disorders, particularly type 2 diabetes mellitus and cardiovascular diseases.

Etiology

The etiology of polycystic ovary syndrome is not completely clear but there is often a family history. Since polycystic ovary syndrome is a hormonal disorder, the disease is more often associated with peripheral insulin resistance and hyperinsulinism. Obesity may also contribute to such abnormalities [2].

Moreover, family history of anovulation and increased androgen levels (testosterone and androstenedione) may also lead to polycystic ovary syndrome.

Epidemiology

Polycystic ovary syndrome most commonly affects females of reproductive age group with a prevalence of 4-12%. Up to 10% of the cases are diagnosed during gynecological visits. The World Health Organization estimates that it affects 116 million women worldwide.

According to one study, a great ethnic variability in hirsutism is observed. Asian women, for instance, have much less hirsutism as compared to white women. The prevalence rate of hirsutism in southern Chinese women is found to be 10.5%. Similarly in women with hirsutism, investigators found a significant increase in incidence of menstrual irregularities, acne, acanthosis nigricans and polycystic ovaries.

Sex distribution
Age distribution

Pathophysiology

In polycystic ovary syndrome, the ovaries are stimulated to release excess amounts of male hormones, particularly testosterone. It is suggested that there is an increase in the serum level of free IGF-1 that stimulates ovarian androgen production. There is also an excessive release of luteinizing hormone by the anterior pituitary gland [3].

Moreover, most of the women presenting with polycystic ovary syndrome are obese and have insulin resistance. The elevated insulin level causes abnormalities of hypothalamic-pituitary axis that lead to the development of polycystic ovary syndrome. In obese women, adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone, and testosterone to estradiol. Thus, the excess of adipose tissue in obese women results in the increased production of both androgens (responsible for hirsutism, acne and virilization) and estrogens.

Polycystic ovary syndrome has a strong genetic evidence and has been found to be associated with a specific FMR1 sub-genotype in the heterozygous females.

Prevention

Polycystic ovary disease cannot be prevented but early diagnosis and treatment helps prevent long term complications such as diabetes and heart diseases. The use of high fiber diet is also helpful.

Summary

Polycystic ovary syndrome (PCOS) is an ovarian dysfunction with the cardinal features of hyperandrogenism and polycystic ovary morphology. The disease is characterized by menstrual irregularities, hirsutism and obesity. It is a common hormonal disorder among the females of reproductive age and is associated with increased risk of type 2 diabetes and cardiovascular events [1].

Patient Information

Polycystic ovary syndrome is one of the most common hormonal disorders of the female gender. The patients usually present with menstrual disturbances, acne and increased facial hair. The disease runs in families, usually affecting females of reproductive age group. Early diagnosis and treatment helps restore fertility and also reduces the risks of complications.

References

Article

  1. Whitaker KN. Polycystic ovary syndrome: an overview. Journal of pharmacy practice. Feb 2011;24(1):94-101.
  2. Kazer R. The etiology of polycystic ovary syndrome (PCO). Medical hypotheses. Nov 1989;30(3):151-155.
  3. Taketani Y. Pathophysiology of polycystic ovary syndrome. Overview. Hormone research. 1990;33 Suppl 2:3-4.
  4. Orsino A, Van Eyk N, Hamilton J. Clinical features, investigations and management of adolescents with polycystic ovary syndrome. Paediatrics & child health. Dec 2005;10(10):602-608.
  5. Li L, Yang D, Chen X, Chen Y, Feng S, Wang L. Clinical and metabolic features of polycystic ovary syndrome. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. May 2007;97(2):129-134.
  6. Goodarzi MO, Dumesic DA, Chazenbalk G, Azziz R. Polycystic ovary syndrome: etiology, pathogenesis and diagnosis. Nature reviews. Endocrinology. Apr 2011;7(4):219-231.
  7. Nakamura Y. Treatment of polycystic ovary syndrome: an overview. Hormone research. 1990;33 Suppl 2:31.
  8. Badawy A, Abdel Aal I, Abulatta M. Clomiphene citrate or anastrozole for ovulation induction in women with polycystic ovary syndrome? A prospective controlled trial. Fertility and sterility. Sep 2009;92(3):860-863.
  9. Ghazeeri GS, Nassar AH, Younes Z, Awwad JT. Pregnancy outcomes and the effect of metformin treatment in women with polycystic ovary syndrome: an overview. Acta obstetricia et gynecologica Scandinavica. Jun 2012;91(6):658-678.
  10. Neveu N, Granger L, St-Michel P, Lavoie HB. Comparison of clomiphene citrate, metformin, or the combination of both for first-line ovulation induction and achievement of pregnancy in 154 women with polycystic ovary syndrome. Fertility and sterility. Jan 2007;87(1):113-120.

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Last updated: 2018-06-21 21:22