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Case Presentation for Polycystic Ovarian Syndrome

Hannah Lattanzio , University of Illinois at Chicago Follow Vered Arbel , University of Illinois at Chicago Follow Terry Nicola Tal Amasay Follow

CASE HISTORY : The patient is a fourteen-year-old female who presented to the clinic for bilateral hip and lumbar back pain. She stated that the pain has been present for approximately seven months and described it as a deep ache in the low back and both hips anteriorly. The patient said she plays a variety of sports but denies any specific event that could contribute to her pain. She stated her pain is worse with prolonged walking, standing, and sitting. Additionally, the patient mentioned her first menstrual cycle lasted fifty-six days and she has since not had any following menses, indicating secondary amenorrhea. Secondary amenorrhea is characterized by the cessation of irregular menses for six months and is commonly caused by hormonal imbalances. PHYSICAL EXAM : Examination of the hip, abdomen, and back did not demonstrate any deformities. She had tenderness to palpation at the mid-abdomen and at the insertion of the hip flexors, at the ASIS and AIIS bilaterally. Her patellar reflex was normal and 5/5 strength in hip flexion, extension, and abduction was observed along with full range of motion of both hips. FABER and FADIR tests were conducted and resulted in a positive sign of pain for both tests. DIFFERENTIAL DIAGNOSES : Hip dysplasia, Slipped capital femoral epiphysis, Polycystic Ovarian Syndrome, Femoroacetabular impingement, and Snapping hip. TESTS & RESULTS : Patient had an x-ray of both hips that were negative for tissue abnormalities. A pelvic MRI suggested small areas of sub-chondral sclerosis and possible polycystic ovaries. FINAL DIAGNOSIS : Polycystic Ovarian Syndrome (PCOS). DISCUSSION : PCOS is a common endocrine disorder that effects an estimated 10% of women between the ages of fifteen to forty-four, though it is commonly diagnosed in adolescence to early twenties. PCOS is diagnosed when two of the following criteria are evident: menstrual irregularity, polycystic ovaries and/or symptoms of androgen excess. Though pain is not an indicator of PCOS, it is not uncommon, and presentation varies widely to include abdominal, anterior pelvic, and low back pain. PCOS is believed to be caused by genetics but is greatly influenced by lifestyle factors and is associated with many morbidities including obesity, insulin resistance, and depression. Management of PCOS consists of controlling the symptoms of androgen excess and/or the absence of ovulation, and to reduce the chances of long-term complications such as infertility, metabolic syndrome, and type two diabetes. Oral contraceptives are the most common treatment for menstrual irregularity in adolescents. Androgen excess is managed with a combination of cosmetic management, oral contraceptives, and anti-androgen therapy, such as cyproterone acetate. Prevention of long-term complications include diet and lifestyle changes to reduce the risk of developing type two diabetes. Metformin may also be an effective treatment for both type two diabetes and androgen excess. OUTCOME OF THE CASE : Patient was referred to physical therapy to include protective range of motion and exercise of hip flexors. She continued to take Diclofenac for pain. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP : The patient will follow-up with endocrinology and gynecologist for questionable polycystic ovarian syndrome due to polycystic ovaries present on the hip MRI and elevated testosterone levels. An x-ray without contrast of bilateral hips will be obtained to evaluate bony anatomy and she will return to the clinic in 4-6 weeks to follow-up on symptoms and discuss the imaging findings.

Recommended Citation

Lattanzio, Hannah; Arbel, Vered; Nicola, Terry; and Amasay, Tal (2020) "Case Presentation for Polycystic Ovarian Syndrome," International Journal of Exercise Science: Conference Proceedings : Vol. 2: Iss. 12, Article 128. Available at: https://digitalcommons.wku.edu/ijesab/vol2/iss12/128

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Text-based cme, journal cme, self-study cme, disease management clinical decisions, clinical overview: polycystic ovarian syndrome, vinni makin, md, face, monica flores, md, case presentation.

A 23-year-old woman presents for obesity (BMI 36.21 kg/m 2 : Height 5 ft-2 in, weight 198 lbs) and irregular menstrual periods. She is concerned that in the last 6 months, she has gained about 17 lbs despite changing her diet and exercising more. She also reports excessive abdominal and facial hair growth and infrequent menstrual cycles in the same time period. Her menstrual cycles were occurring every 28 days, but now the average interval is about 45 days. She denies other symptoms such as deepening of her voice, fatigue, abdominal cramps, increase/loss appetite, diarrhea/constipation, or cold-hot intolerance. She is not interested in fertility at this time.

Her medical history is significant for the following:

• Menarche at age 13. Initially, her menstrual cycles were irregular, but after 1 year, they had normalized;
• Needs waxing or shaving of facial hair since age 16;
• Has insomnia managed with zaleplon 5 mg capsule before bedtime.

Her family history is significant for the following:

• Father with hypertension, hyperlipidemia, and obesity;
• Mother with type 2 diabetes, obesity, and hyperthyroidism;
• Sister with polycystic ovarian syndrome (PCOS).

Her social history shows that she has had the same sexual partner for last 2 years and no pregnancies. She has worked full-time as teacher for the past 2 years.

The physical examination shows the following:

• Blood pressure 109/59 mmHg; pulse is 66 beats per minute.
• Appearance: Well and alert. Generally obese. Mild acanthosis nigricans on dorsum of neck. No rounded facies or supraclavicular fat tissue.
• Neck: Supple, no palpable adenopathy; thyroid symmetric, normal size; no bruits.
• Cardiovascular system: Regular rhythm without appreciable murmur. Normal S1 and S2 sounds; no S3 or S4.
• Abdominal: Bowel sounds normoactive, no bruits. Abdomen is soft, nontender, nondistended, and not tender when palpated.
• Skin: Mild acne scarring, but no current significant acne; dark hair noted on upper lip, upper arms, low back, and abdomen (Ferriman-Gallwey score: 9).
• Which of the following is the most likely diagnosis?
• A. Cushing syndrome
• B. Polycystic ovarian syndrome
• C. Adrenal tumor
• D. Hypothyroidism

Correct: B. Polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women around the world. The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) recommend using the Rotterdam criteria for its diagnosis (Table 1). 1-2

Our patient fulfills 2 out of 3 of the diagnostic criteria — oligomenorrhea (menstrual cycles >35 days) and hirsutism, which was quantified with the Ferriman-Gallwey score of 9 (score ≥ 8 indicates hirsutism) — suggesting the diagnosis of PCOS.

In addition to PCOS, there are numerous other disorders of androgen excess in women, including adrenal hyperplasia, thyroid dysfunction, hyperprolactinemia, Cushing syndrome, and androgen secretin tumors.

Cushing syndrome can present with rapid weight gain, oligomenorrhea, signs of hyperandrogenism, possible impaired glucose tolerance, and hypertension. The absence of physical findings in this case, such as reddish abdominal striae and Cushing facies or prominent central obesity with peripheral muscle wasting, makes the diagnosis less likely.  

Adrenal tumors can present with hirsutism and amenorrhea, but they usually they progress rapidly to virilization. In case of virilization, clitoromegaly and deepening of voice can be evident.

Hypothyroidism is associated with chronic anovulation and usually mild hirsutism which can resemble lanugo hair. In this case hirsutism was notorious and patient lacked of other common symptoms of hypothyroidism.

• What is the most appropriate next step to diagnose this patient’s condition?
• A. Obtain pelvic ultrasonography
• B. Obtain total testosterone and sex hormone-binding globulin levels
• C. Obtain thyroid stimulating hormone, prolactin, and 17-hydroxyprogesterone levels
• D. Obtain LH/ FSH ratio

Answer: C. Obtain thyroid stimulating hormone, prolactin, and 17-hydroxyprogesterone levels

In addition to the diagnostic criteria, the evaluation and diagnosis of PCOS needs to exclude common alternate androgen-excess disorders. These disorders include, in all women, thyroid disease, hyperprolactinemia, and nonclassic congenital adrenal hyperplasia (primarily 21-hydroxylase deficiency by serum 17-hydroxyprogesterone). In select women with amenorrhea and more severe phenotypes, more extensive evaluation should be done to exclude other causes.

As part of the initial assessment of biochemical hyperandrogenism, measurement of total testosterone and sex hormone–binding globulin should be obtained. Serum testosterone levels above the reference ranges indicates hyperandrogenemia. According to AACE guidelines, 3 free testosterone is the most sensitive test for hyperandrogenemia in women with PCOS; however, direct free testosterone assays are notoriously inaccurate, so it is more appropriate to calculate free testosterone using measurements of total testosterone and sex hormone-binding globulin. In our patient, testosterone levels can be obtained for further evaluation, but the patient already has clinical signs of hyperandrogenism. 

If a women has both oligomenorrhea or amenorrhea and clinical or biochemical evidence of hyperandrogenism, the diagnostic criteria have been met; therefore, ultrasonography to determine the presence of polycystic ovaries is unnecessary.

Measurement of LH/FSH ratio is of limited use in the diagnosis of PCOS since it lacks of specificity because of the pulsatile nature of their release so a single test fails to detect an increased LH/FSH ratio.

We ordered several laboratory tests for our patient. Table 2 lists the test results.

Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein; TC, total cholesterol; VLDL, very low-density lipoprotein 

• What other screening tests should be ordered for this patient?
• A. Hemoglobin A1c
• B. STOP-BANG sleep apnea questionnaire
• C. All of the above

Answer: C. All of the above

Longitudinal screening for cardiometabolic risk factors is recommend in all patients with PCOS. Screening for metabolic abnormalities includes glucose intolerance and dyslipidemia. Although most guidelines suggest screening for impaired glucose tolerance and type 2 diabetes with the use of the 2-hour oral glucose-tolerance test, measurement of the glycated hemoglobin level for initial screening can be done for the patient’s convenience.

Also, screening for obstructive sleep apnea, hypertension, nonalcoholic fatty liver disease, anxiety, and depression should be consider based on this patient’s age and presentation.

We ordered additional tests for the patient. Results are shown in Table 3.

Abbreviations: FSH, follicle stimulating hormone; TSH, thyroid stimulating hormone, SHBG: sex hormone binding globulin

Our first step for patient management was to recommend a weight-loss regimen before prescribing pharmacologic therapy.   

• Which one of the following would be the first-line pharmacologic therapy for this patient?
• A. Metformin
• B. Hormonal contraception 
• C. Clomiphene
• D. Letrozole

Answer: B. Hormonal contraception

PCOS is a lifelong disorder and initiating pharmacologic therapy and lifestyle measurements that improve metabolic and endocrine status are important to reduce the risk of cardiovascular disease. Weight loss is the primary nonpharmacological therapy in PCOS. Weight reductions of as little as 5% can restore regular menses and improve response to ovulation-inducing and fertility. 4

Hormonal contraceptives are the first-line pharmacologic therapy for treatment of menstrual irregularity in patients who do not desire pregnancy. They also ameliorate features of hyperandrogenism and provide endometrial protection through withdrawal bleeding.

Additional pharmacologic options include metformin, which may be added to target metabolic abnormalities and is best used as an adjuvant to lifestyle modification. It is also consider as a second-line therapy in patients who cannot take or do not tolerate hormonal contraception because it has some efficacy in normalizing ovulatory cyclicity but minimal impact on hirsutism.

Clomiphene and Letrozole are consider the first-line treatment of anovulatory infertility in women with PCOS.

Patient was placed on an oral ethinyl estradiol-drospirenone contraceptive (Yasmin) after a pregnancy test confirmed her nonpregnant status. Because her hemoglobin A1c was 6.0%, she was also started on extended-release metformin at 500 mg daily. She was referred to a dietician for dietary counseling and conservative weight loss. She was advised on the long-term risks of PCOS including increased risk for diabetes, coronary heart disease, and hyperlipidemia. 

• Patients with PCOS are at increased risk for which of the following malignancies?
• A. Endometrial cancer
• B. Ovarian cancer
• C. Breast cancer
• D. Cervical cancer

Answer: A. Endometrial cancer

The risk of endometrial cancer is estimated to be 2.7 times higher in women with PCOS than in women without the syndrome. 5 Guidelines do not recommend routine screening for endometrial hyperplasia with ultrasonography or biopsy, but they provide support for referral to a gynecologist in patients with prolonged amenorrhea or persistently abnormal vaginal bleeding. 3

Six months later, the patient returns for a follow-up appointment. She says she is feeling better, her menstrual periods have become regular, and she has been able to lose 10 pounds.  Her primary concern is her excess hair growth — she needs to shave or tweeze every 3 days. Physical examination is consistent with mild hirsutism involving upper lip, upper arm, abdomen, and lower back. The patient wants to continue with oral contraception because she has no plan for pregnancy at the moment.

• Which medication can be added to her oral contraceptive for hirsutism management?
• A. Spironolactone
• B. Eflornithine
• C. Minoxidil
• D. Laser hair removal

Answer: A. Spironolactone

Treatment should be based on the patient’s perception of the problem, rather than on a quality or quantity assessment of hirsutism by a clinician. Antiandrogen drugs such as spironolactone can be added after 6 months if results of hormonal contraceptives are suboptimal, preferably in combination with an oral contraceptive. It should not be used if pregnancy is a consideration. Eflornithine is a topical treatment for facial hirsutism that slows the growth of unwanted hair. This medication inhibits ornithine decarboxylase, an enzyme that catalyzes biosynthesis of intracellular polyamines required for cell division and differentiation, which, in turn, can affect hair growth. It has to be applied twice a day and is useful if the hirsutism is confined to a small part of the body and not generalized. Because this patient’s hirsutism involves large areas of her body, this medication would not be the right choice for her.  

Minoxidil is used to promote hair growth for androgenic alopecia, which is not our patient’s concern.

In women with PCOS, laser treatment is associated with a poorer reduction in hair counts and hair free interval following treatment. 6

Three years later, this patient presents for pregnancy evaluation. She discontinued her hormonal contraception 1 year ago and since then has been trying to become pregnant, although unsuccessfully. Her partner has a biological child who is 7 years old from an earlier relationship.

• What would be the next best step strategy?
• A. In vitro fertilization
• B. Clomiphene citrate
• C. Increase metformin dose
• D. Avoid pregnancy

Answer: B. Clomiphene citrate

Clomiphene citrate (or a comparable estrogen modulator such as letrozole) is the first-line treatment of anovulatory infertility in women with PCOS. In vitro fertilization is considered when lifestyle measures and ovulation-induction agents are unsuccessful. The use of metformin is suggested as an adjuvant therapy for infertility to prevent ovarian hyperstimulation syndrome in women with PCOS undergoing in vitro fertilization.

• What are the potential drawbacks to clomiphene citrate use for ovulation induction?
• A. Mood change and hot flashes
• B. Relatively high multiple-pregnancy rate
• C. Overall low live birth and ovulation rate
• D. All of the above

Answer: D. All of the above

Discussion 

Clomiphene citrate is a selective estrogen-receptor modulator that antagonizes the negative feedback of estrogen at the hypothalamus with a consequent increase in ovarian stimulation by endogenous gonadotropin. It is considered to be the first-line infertility treatment in women with PCOS. Clomiphene has drawbacks, including its overall poor efficacy (only a 22% rate of live birth with up to six cycles of clomiphene in our previous study), a relatively high multiple-pregnancy rate (3 to 8%) as compared with the rate associated with unassisted conception (<1%), and an undesirable side-effect profile, including mood changes and hot flashes. 7

As an option, letrozole has been used off-label for infertility in women with PCOS and infertility. According to a double-blind, multicenter trial published in 2014, aromatase inhibitors, such as letrozole, appear to have better pregnancy outcomes than clomiphene. Women who received letrozole had more cumulative live births than those who received clomiphene (103 of 374 [27.5%] vs 72 of 376 [19.1%], P = 0.007; rate ratio for live birth, 1.44; 95% confidence interval, 1.10 to 1.87). 7

After 6 months of glucose control, menstrual regularity, and increasing doses of metformin and letrozole, she became pregnant.

• Polycystic ovary syndrome (PCOS) is one of the most common causes of hyperandrogenism in reproductive-aged women.
• Common clinical manifestations of PCOS include oligomenorrhea, acne, and hirsutism.
• Use the Rotterdam criteria is commonly used for diagnosing PCOS (presence of at least two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries).
• Evaluation of women with PCOS should exclude alternate androgen-excess disorders and assess for risk factors of endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease.
• Weight loss is the primary nonpharmacological therapy in PCOS. Weight reductions of as little as 5% can restore regular menses and improve response to ovulation-inducing and fertility.
• Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in women with PCOS not desiring fertility at the time.
• Clomiphene or letrozole are currently the first-line therapies for infertility.
• Metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility.
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Polycystic ovarian syndrome (PCOS ）

Sep 15, 2014

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Polycystic ovarian syndrome (PCOS ）. Wei Zhang OB/GYN Hospital, Fudan University. Content. OVERVIEW of PCOS PATHOPHYSIOLOGY SIGNS and SYMPTOMS DIAGNOSTIC CRITERIA TREATMENT. OVERVIEW. PCOS. 1 st described by Stein and Leventhal as a triad of amenorrhea, obesity and hirsutism (1935)

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Polycystic ovarian syndrome(PCOS） Wei Zhang OB/GYN Hospital, Fudan University

Content • OVERVIEW of PCOS • PATHOPHYSIOLOGY • SIGNS and SYMPTOMS • DIAGNOSTIC CRITERIA • TREATMENT

PCOS • 1 st described by Stein and Leventhal as a triad of amenorrhea, obesity and hirsutism (1935) • The symptoms and severity of the syndrome vary greatly among affected women • It is one of the leading causes of female infertility

Definition & Abbreviations • Definition :Polycystic ovarian syndrome is a common endocrine disfunction typified by oligo-ovulation or anovulation, signs of androgen excess, and multiple small ovarian cysts • Abbreviations • PCOS = Polycystic Ovarian Syndrome • PCO= Polycystic Ovarian

Incidence • PCOS is the most common disorder of reproductive-aged women • Affects approximately 4-12% • PCOS appears to equally affect all races and nationalities

Etiology • Genetic basis • Aggregation of the syndrome within families • An increased prevalence has been noted between affected individuals and their sisters and mothers • The first-degree male relatives of women with PCOS have significantly higher circulating DHEAS levels

Environment causes • Life style • Exercise • Diet • Androgen exposure, et. al

Interaction of Genetics and environment PCOS may be a genetically determined ovarian disorder , the heterogeneity can be explained on the basis of interaction of the disorder with other genes and with the environment

PATHOPHYSIOLOGY

Reproductive cycle regulated by HPOaxis Hypothalamus GnRH Pituitary Gn FSH LH Ovary Progesterone Estradiol 内膜

Pathopysiologyz:What we think we know • Abnormal gonadotropin secretion • Excess LH and low, tonic FSH • Hypersecretion of androgens • Disrupts follicle maturation • Substrate for peripheral aromatization • Negative feedback on pituitary • Decreased FSH secreation • Insulin resistance, Elevated insulin levels

Disorder of H-P-O axis • Increased GnRH from hypothalamus • Excessive LH secretion relative to FSH by pituitary gland • LH stimulates ovarian thecal cells to produce excessive androgen • Ineffective suppression of the LH pulse frequency by estradiol and progesterone • Androgen excess increases LH by blocking the hypothalamic inhibitory feedback of progesterone

H-P-O axis Dysfunction in PCOS GnRH Estrogen androgen LH, FSH Anovulation

Abnormal steroidogenesis • Intraovarian androgen excess results in excessive growth of small ovarian follicles • Follicular maturation is inhibited • Excess androgen causes thecal and stromal hyperplasia

PCO • These "cysts" are actually immature follicles. The follicles development stopped at an early antral stage due to the disturbed ovarian function • Polycystic is >12 follicles per ovary less than 10mm in diameter, ovary itself is enlarged

Metabolism disorder • Hyperinsulinemia • Excess insulin production and insulin resistance • Hyperinsulinemia contributes to hyperandrogenism through production in the theca cell and through its suppressive effects on sex hormone binding globulin production by the liver • Hyperandrogenism vs. hyperinsulinemia: Which came first? • Dyslipidemia

Current theories of pathopysiology Autosomal Dominant Gene Downstream Signal Defect GnRH E2 LH Insulin Resistance PCOS A A=androgens, E2=estradiol

SIGNS and SYMPTOM

Clinical Features of PCOS • Hyperandrogenism • Hirsutism • Acne • Chronic anovulation (irregular menses) • Irregular menses • Infertility • Endocrine Dysfunction • Obesity • Insulin resistance • Acanthosis Nigricans • Impaired Glucose Tolerance and Type 2 Diabetes Mellitus • Dyslipidemia • Metabolic Syndrome and Cardiovascular Disease • Polycystic ovaries

Hyperandrogenism • Hirsutism, acne, male pattern balding, alopecia • 50-90% patients have elevated serum androgen levels • Rare: increased muscle mass, deepening voice,

Hirsutism:Ferriman-Gallwey Scoring System • Acne: 50% • Mild • moderate • severe

Facial Hirsutism in PCOS

Chronic anovulation/oligo-ovulation • Menstrual Dysfunction • Oligomenorrhea : 70-75 % • Amenorrhea: 20 % • Regular cycles: 5-10 % • Infertility: 30-70%

Menstrual Dysfunction • Oligo or amenorrhea • Menstrual irregularity typically begins in the peripubertal period • Reduction in ovulatory events leads to deficient progesterone secretion • Chronic estrogen stimulation of the endometrium with no progesterone for differentiation—intermittent breakthrough bleeding or dysfunctional uterine bleeding • Increased risk for endometrial hyperplasia and/or endometrial CA

INFERTILITY • Intermittent ovulation or anovulation • Inherent ovarian disorder—studies show reduced rated of conception despite therapy with clomid

Obesity • Prevalence of obesity varies from 30-75% • 2/3 of patients with PCOS who are not obese have excessive body fat and central adiposity • Obese patients can be hirsute and/or have menstrual irregularities without having PCOS

Insulin Resistance • > 80% are hyperinsulinemic and have insulin resistance (independent of obesity)

Acanthosis Nigricans • Velvety plaques on • nape of neck and • intertriginous • areas • Epidermal • hyperkeratosis • Associated with • insulin resistance

Ovarian Abnormalities • Thickened sclerotic cortex • Multiple follicles in peripheral location • 80% of women with PCOS have classic cysts

Associated Medical Conditions • Increased risk of developing Type 2 Diabetes and Gestational diabetes • Low HDL and high triglycerides • Sleep apnea • Nonalcoholic steatohepatitis • Metabolic syndrome—43% of PCOS patients (2 fold higher than age-matched population) • Elevated heart disease • Advanced atherosclerosis

Consequences of PCOS • Short-term consequences • Irregular menses • Hirsutism/acne/androgenic alopecia   • Infertility • Obesity  • Metabolic disturbances : Abnormal lipid levels/glucose intolerance • Long-term consequences • Diabetes mellitus (DM) • Cardiovascular disease(CVD) • Endometrial cancer

Consequences of PCOS Short-term consequences Hirsutism, acne Menstrual irregularity hyperandrogen infertility Obesity PCOS hyperplasia/cancer Long-term consequences CVD Elevated insulin Dyslipidemia diabetes

DIAGNOSTIC CRITERIA

Difficult to diagnosis • Changing criteria • Varying symptoms over time • Not all women with PCOS have polycystic ovaries (PCO), nor do all women 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

NIH Criteria(1990) • Menstrual irregularity due to anovulation or oligo-ovulation • Evidence of clinical or biochemical hyperandrogenism • Hirsutism, acne, male pattern baldness • High serum androgen levels • Exclusion of other causes (CAH, tumors, hyperprolactinemia)

2003 Rotterdam Criteria (2 out of 3) • Menstrual irregularity due to anovulation oligo-ovulation • Evidence of clinical or biochemical hyperandrogenism • Polycystic ovaries by US • 12 or more follicles measuring 2-9 mm in diameter • Increased ovarian volume (>10 cm 3 ) • Exclusion of other causes (CAH, tumors, hyperprolactinemia) In 2003 in Rotterdam, Netherlands, a consensus meeting between the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine (ESHRE/ASRM) redefined PCOS

Differential Diagnosis • Hyperprolactinemia • Prominent menstrual dysfunction • Little hyperandrogenism 2. Congenital Adrenal Hyperplasia • morning serum 17-hydroxyprogesterone concentration greater than 200 ng/dL in the early follicular phase strongly suggests the diagnosis • confirmed by a high dose (250 mcg) ACTH stimulation test: post-ACTH serum 17-hydroxyprogesterone value less than 1000 ng/dL

3. Ovarian and adrenal tumors • serum testosterone concentrations are always higher than 150 ng/dL • adrenal tumors: serum DHEA-S concentrations higher than 800 mcg/dL • LOW serum LH concentrations 4. Cushing’s syndrome 5. Drugs: danazol; OCPs with high androgenicity

Diagnostic Approaches • Clinical history (hair growth rate, • onset of symptoms) • Physical examination (hirsutism or • virilization, rounded facies, buffalo hump) • Laboratory testing (hormones) • Ultrasonography (ovary, endometrium)

LaboratoryTesting • Fasting glucose: elevated • 2 hour OGTT: elevated • Fasting insulin: elevated • Free testosterone: elevated • DHEA-S: normal • 17-hydroxyprogesterone: normal • Pelvic US • Lipids profile

Laboratory Evaluation Total Testosterone (T) DHEA-S (DS) 17-hyroxyprogesterone (17-OHP) T > 200 ng/dl DS > 700 μg/dl T Elevated ± DS Elevated DS Elevated Adrenal Suspect Tumor PCOS T & DS Normal 17-OHP > 2 ng/ml Idiopathic SuspectCAH

Treatment • Goals of PCOS Treatment • Restoration a normal cycle and fertility • Lowering of insulin levels • Treatment of hirsutism, acne • Prenvention of endometrial cancer • Prevention of DM,CVD and metabolic syndrome

Treatment Option • Lifestyle modification • Anti-androgens • Insulin lowering agents • Induced ovulation-for pregnancy desired

Lifestyle modification • Weight loss: • Low-carbohydrate diets • sustained regular exercise • 90% of anovulatory women restored to full ovulation despite relatively small amounts of weight loss following exercise and change of diet • BMI of 21 is ideal but the patient often respond to much less stringent body mass index

Anti-Androgen • OCPs: first option when fertility is not desired • Decrease in LH secretion and decrease in androgen production • Increase in hepatic production of sex-hormone binding globulin(SHBG) • Decreased bioavailablity of testosterone • Decreased adrenal androgen secretion • Regular withdrawal bleeding • Prevention of endometrial hyperplasia

Spironolactone, 50-200 mg per day • Androgen receptor blockade • Steroid enzyme inhibition • Aldosterone antagonism • Lower blood pressure • Potassium sparing

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POLYCYSTIC OVARY SYNDROME (PCOS)

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Presentation on theme: "POLYCYSTIC OVARY SYNDROME (PCOS)"— Presentation transcript:

PCOS and Fertility Positive Steps Forward

MANAGEMENT OF INFERTILITY CURRENT GUIDELINES

 Ultrasound pelvis  Full blood count  Pap smear  Coagulation profile  Liver function tests  Serum Iron  Serum ferritin  Endometrial biopsy 

Different Faces of PCOS (Polycystic Ovarian Syndrome)

Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovary Syndrome & Metformin November 19, 2008.

Infertility and PCOS Erinn Myers, M4 Department of Obstetrics and Gynecology University of Tennessee Health Science Center January 28, 2007.

Al- Jalla Maternity Hospital

Biomarkers of ovarian cancer and cysts Reproductive Block 1 Lecture By: Reem Sallam, MD, MSc, PhD.

DR. ZEINAB ABOTALIB Professor & Consultant Obstetrics & Gynecology Dept.

IN THE NAME OF GOD Elham Faghihimani endocrinologist.

Valerie Robinson, DO. Polycystic Ovarian Syndrome (PCOS) is a disorder that causes menstrual and ovulation irregularities, androgen excess, and infertility.

© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 154 (3): ITC2-1. Terms of Use  The In the Clinic ® slide sets are owned and copyrighted by.

Polycystic ovarian syndrome: an Asian phenomenon?

Polycystic ovarian syndrome PCO

PCOS Polycystic Ovary Syndrome

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INFERTILITY ASSOCIATED WITH PCOS Dr. Norlia Bahauddin Hospital Kajang.

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Polycystic Ovarian Syndrome Clinical Presentation

• Author: Richard Scott Lucidi, MD, FACOG; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
• Sections Polycystic Ovarian Syndrome
• Practice Essentials
• Epidemiology
• Patient Education
• Physical Examination
• Approach Considerations
• Screening Laboratory Studies
• Hormone Levels
• Glucose, Insulin, and Lipids
• Imaging for PCOS
• Histologic Findings
• Lifestyle Modifications
• Drug Treatment
• FDA Safety Alerts
• Metabolic Derangements
• Anovulation
• Diet and Activity
• Surgical Intervention
• Long-Term Monitoring
• Medication Summary
• Hypoglycemic Agents
• Antiandrogens
• Topical Hair-Removal Agents
• Oral Contraceptives
• Selective Estrogen Receptor Modulators
• Acne Agents, Topical
• Questions & Answers
• Media Gallery

The family history of patients with polycystic ovarian syndrome (PCOS) may include the following:

Menstrual disorders

Adrenal enzyme deficiencies

• Infertility

Obesity and metabolic syndrome

Menstrual abnormalities.

Patients with PCOS have abnormal menstruation patterns attributed to chronic anovulation. (The patient usually has a history of menstrual disturbance dating back to menarche.) Some women have oligomenorrhea (ie, menstrual bleeding that occurs at intervals of 35 days to 6 months, with < 9 menstrual periods per year) or secondary amenorrhea (an absence of menstruation for 6 months). Dysfunctional uterine bleeding and infertility are the other consequences of anovulatory menstrual cycles. The menstrual irregularities in PCOS usually present around the time of menarche.

A retrospective study by Maslyanskaya et al reported that PCOS was the most common etiology seen in adolescent patients hospitalized for abnormal uterine bleeding (accounting for 33% of 125 hospital admissions). [ 40 ]

Hyperandrogenism

Hyperandrogenism clinically manifests as excess terminal body hair in a male distribution pattern. Hair is commonly seen on the upper lip, on the chin, around the nipples, and along the linea alba of the lower abdomen. Some patients have acne and/or male-pattern hair loss (androgenic alopecia).

Other signs of hyperandrogenism (eg, clitoromegaly, increased muscle mass, voice deepening) are more characteristic of an extreme form of PCOS termed hyperthecosis. These signs and symptoms could also be consistent with androgen-producing tumors, exogenous androgen administration, or virilizing congenital adrenal hyperplasia.

Premature adrenarche is a common occurrence and, in some cases, may represent a precursor to PCOS. Hirsutism and obesity may be present in premenarchal adolescent girls with PCOS.

The American College of Obstetricians and Gynecologists (ACOG) recommends screening with 17-hydroxyprogesterone levels in women suspected of having PCOS who are at an increased risk for nonclassical congenital adrenal hyperplasia. [ 5 ]

A subset of women with PCOS is infertile. Most women with PCOS ovulate intermittently. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned. In addition, the rate of miscarriage is also higher in affected women.

Nearly half of all women with PCOS are clinically obese. A study comparing the body mass index (BMI) in American and Italian women with PCOS showed that American women had a BMI higher than that of their Italian counterparts. [ 41 ] Women with PCOS should be assessed for their cardiovascular risk by evaluating their BMI, fasting lipid and lipoprotein levels, and risk factors for metabolic syndrome. [ 5 , 6 ]

Many patients with PCOS have characteristics of metabolic syndrome; one study showed a 43% prevalence of metabolic syndrome in women with PCOS. [ 28 ] In women, metabolic syndrome is characterized by abdominal obesity (waist circumference >35 in), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] level < 50 mg/dL), elevated blood pressure, a proinflammatory state characterized by an elevated C-reactive protein level, and a prothrombotic state characterized by elevated plasminogen activator inhibitor-1 (PAI-1) and fibrinogen levels. [ 28 ]

Women with PCOS have an increased prevalence of coronary artery calcification and thickened carotid intima media, which may be responsible for subclinical atherosclerosis. Prospective, long-term cardiovascular-outcome studies in PCOS are needed to assess whether the increased cardiovascular risk in PCOS results in the higher cardiovascular-event rates.

Diabetes mellitus

ACOG recommends screening for type 2 diabetes and impaired glucose tolerance in women with PCOS by obtaining a fasting glucose level and then a 2-hour glucose level after a 75-g glucose load. [ 5 ] Approximately 10% of women with PCOS have type 2 diabetes mellitus, and 30-40% of women with PCOS have impaired glucose tolerance by 40 years of age. [ 42 , 43 ]

Sleep apnea

Many women with PCOS have obstructive sleep apnea syndrome (OSAS), which is an independent risk factor for cardiovascular disease. [ 6 ] Ask these patients and/or their partners about excessive daytime somnolence; individuals with obstructive sleep apnea experience apnea/hypopnea episodes during sleep. [ 44 , 45 ] For women with PCOS with suspected OSAS, there should be a low threshold for referral for sleep assessment. Patients may also be screened for OSAS in the clinic using such tools as the Epworth sleepiness score.

Hirsutism and virilizing signs

Patients may have excessive body hair in a male distribution pattern, as well as acne. Some patients have virilizing signs, such as male-pattern balding or alopecia, increased muscle mass, deepening voice, or clitoromegaly; these findings should prompt a search for other causes of hyperandrogenism.

The modified Ferriman-Gallwey (mFG) score grades 9 body areas from 0 (no hair) to 4 (frankly virile), including the upper lip, chin, chest, upper abdomen, lower abdomen, thighs, back, arm, and buttocks. A total score of 8 or more is considered abnormal for an adult white woman; a score of 36 is the most severe.

Approximately 50% of women with polycystic ovarian syndrome (PCOS) have abdominal obesity, characterized by a waist circumference greater than 35 inches (>88 cm).

Acanthosis nigricans

Acanthosis nigricans is a diffuse, velvety thickening and hyperpigmentation of the skin. It may be present at the nape of the neck, axillae, area beneath the breasts, intertriginous areas, and exposed areas (eg, elbows, knuckles). In patients with PCOS, acanthosis nigricans is thought to be the result of insulin resistance, although syndromic and familial variants are described. Acanthosis nigricans can also be a cutaneous marker of malignancy.

Acanthosis nigricans is staged according to the scoring system below:

Absent (0): Not detectable on close inspection

Present (1): Clearly present on close visual inspection, not visible to the casual observer, extent not measurable

Mild (2): Limited to the base of the skull, usually does not extend to the lateral margins of the neck

Moderate (3): Extends to the lateral margins of the neck but not visible anteriorly

Severe (4): Visible anteriorly

Severe (5): Circumferential

Blood pressure

Patients with signs and symptoms of metabolic syndrome may have elevated blood pressure, with a systolic blood pressure of 130 mm Hg or higher and a diastolic blood pressure of 85 mm Hg or higher.

Enlarged ovaries

Enlarged ovaries may not always be present. Evaluate for an ovarian mass.

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Sinawat S, Buppasiri P, Lumbiganon P, Pattanittum P. Long versus short course treatment with metformin and clomiphene citrate for ovulation induction in women with PCOS. Cochrane Database Syst Rev . 2008 Jan 23. CD006226. [QxMD MEDLINE Link] .

Badawy A, State O, Abdelgawad S. N-Acetyl cysteine and clomiphene citrate for induction of ovulation in polycystic ovary syndrome: a cross-over trial. Acta Obstet Gynecol Scand . 2007. 86(2):218-22. [QxMD MEDLINE Link] .

Chen ZJ, Shi Y, Sun Y, et al. Fresh versus Frozen Embryos for Infertility in the Polycystic Ovary Syndrome. N Engl J Med . 2016 Aug 11. 375(6):523-533. [QxMD MEDLINE Link] .

Hackethal V. Frozen Embryos Tied to Higher Live Birth Rates in PCOS. Medscape Medical News. Available at https://www.medscape.com/viewarticle/867343 . August 11, 2016; Accessed: August 11, 2016.

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Roth LW, Huang H, Legro RS, et al. Altering hirsutism through ovulation induction in women with polycystic ovary syndrome. Obstet Gynecol . 2012 Jun. 119(6):1151-6. [QxMD MEDLINE Link] . [Full Text] .

Liepa GU, Sengupta A, Karsies D. Polycystic ovary syndrome (PCOS) and other androgen excess-related conditions: can changes in dietary intake make a difference?. Nutr Clin Pract . 2008 Feb. 23(1):63-71. [QxMD MEDLINE Link] .

Ornstein RM, Copperman NM, Jacobson MS. Effect of weight loss on menstrual function in adolescents with polycystic ovary syndrome. J Pediatr Adolesc Gynecol . 2011 Jun. 24(3):161-5. [QxMD MEDLINE Link] .

Cussons AJ, Watts GF, Mori TA, Stuckey BG. Omega-3 fatty acid supplementation decreases liver fat content in polycystic ovary syndrome: a randomized controlled trial employing proton magnetic resonance spectroscopy. J Clin Endocrinol Metab . 2009 Oct. 94(10):3842-8. [QxMD MEDLINE Link] .

Jamilian M, Asemi Z. The Effects of Soy Isoflavones on Metabolic Status of Patients With Polycystic Ovary Syndrome. J Clin Endocrinol Metab . 2016 Aug 4. jc20161762. [QxMD MEDLINE Link] .

Busko M. Soy Isoflavones Tied to Improved Metabolic Markers in PCOS. https://www.medscape.com/viewarticle/867076#vp_2. Available at https://www.medscape.com/viewarticle/867076#vp_2 . August 04, 2016; Accessed: August 11, 2016.

Wehr E, Pilz S, Schweighofer N, et al. Association of hypovitaminosis D with metabolic disturbances in polycystic ovary syndrome. Eur J Endocrinol . 2009 Oct. 161(4):575-82. [QxMD MEDLINE Link] .

Poujade O, Gervaise A, Faivre E, Deffieux X, Fernandez H. Surgical management of infertility due to polycystic ovarian syndrome after failure of medical management. Eur J Obstet Gynecol Reprod Biol . 2011 Oct. 158(2):242-7. [QxMD MEDLINE Link] .

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Roos N, Kieler H, Sahlin L, et al. Risk of adverse pregnancy outcomes in women with polycystic ovary syndrome: population based cohort study. BMJ . 2011 Oct 13. 343:d6309. [QxMD MEDLINE Link] . [Full Text] .

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• Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles.
• Low power, H and E of an ovary containing multiple cystic follicles in a patient with PCOS.

Contributor Information and Disclosures

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine Disclosure: Nothing to disclose.

Frances E Casey, MD, MPH Associate Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Reproductive Health Professionals , National Abortion Federation , Physicians for Reproductive Health , Society of Family Planning Disclosure: Nothing to disclose.

Elizabeth Alderman, MD Director of Fellowship Training Program, Director of Adolescent Ambulatory Service, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics , American Pediatric Society , North American Society for Pediatric and Adolescent Gynecology , and Society for Adolescent Medicine

Disclosure: Merck Honoraria Speaking and teaching

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners , American College of Obstetricians and Gynecologists , American Medical Association , Association of Military Surgeons of the US , and Utah Medical Association

Disclosure: Nothing to disclose.

Robert J Ferry Jr, MD Le Bonheur Chair of Excellence in Endocrinology, Professor and Chief, Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Tennessee Health Science Center

Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics , American Diabetes Association , American Medical Association , Endocrine Society , Pediatric Endocrine Society , Society for Pediatric Research , and Texas Pediatric Society

Disclosure: Eli Lilly & Co Grant/research funds Investigator; MacroGenics, Inc Grant/research funds Investigator; Ipsen, SA (formerly Tercica, Inc) Grant/research funds Investigator; NovoNordisk SA Grant/research funds Investigator; Diamyd Grant/research funds Investigator; Bristol-Myers-Squibb Grant/research funds Other; Amylin Other; Pfizer Grant/research funds Other; Takeda Grant/research funds Other

Stephen Kemp, MD, PhD Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics , American Association of Clinical Endocrinologists , American Pediatric Society , Endocrine Society , Phi Beta Kappa , Southern Medical Association , and Southern Society for Pediatric Research

Lynne Lipton Levitsky, MD Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School

Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Pediatrics , American Diabetes Association , American Pediatric Society , Endocrine Society , Pediatric Endocrine Society , and Society for Pediatric Research

Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds Other; Eli Lily Grant/research funds PI; NovoNordisk Grant/research funds PI; NovoNordisk Consulting fee Consulting; Onyx Heart Valve Consulting fee Consulting

Jordan G Pritzker, MD, MBA, FACOG Assistant Professor of Obstetrics/Gynecology and Women's Health, Women's Comprehensive Health Center, Hofstra University School of Medicine; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center

Kathy Silverman, DO Albert Einstein College of Medicine and Montefiore Medical Center

Phyllis W Speiser, MD Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Hofstra-North Shore LIJ School of Medicine at Hofstra University

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists , Endocrine Society , Pediatric Endocrine Society , and Society for Pediatric Research

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Andrea Leigh Zaenglein, MD Associate Professor of Dermatology and Pediatrics, Department of Dermatology, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Andrea Leigh Zaenglein, MD is a member of the following medical societies: American Academy of Dermatology , American Acne and Rosacea Society, and Society for Pediatric Dermatology

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Polycystic Ovary Syndrome (PCOS)

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Some women have a condition in which their ovaries generate abnormal quantities of androgens. These are a type of hormones that control lots of processes in their bodies, and this dysregulation can cause missed periods, hirsutism, infertility and acne, among many others. There is little to no information about this available to women, specially young ones who must be specially aware of the symptoms of irregular periods. Speak about PCOS, the illness that causes all these symptoms, and raise awareness on this issue!

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Pathophysiology & Clinical Presentation

Normal physiology.

Ovaries are organs found on both sides of the uterus in females. Ovaries sit on the ovarian fossa and are connected by ligaments. These important organs have two main jobs: to release female sex hormones, estrogen and progesterone, and to produce ova or eggs.

In a healthy individual, there is a normal hormonal feedback system which enables the body to stimulate the menstrual cycle. A female is born with all the eggs she will produce in her life. Over time these eggs, which are encapsulated in what is termed a follicle, will mature. This happens in the first half of the menstrual cycle. The ovaries will also produce estrogen during the maturation process. In each cycle, one of the mature eggs is eventually released into the fallopian tube, which is called ovulation. The corpus luteum is the leftover follicle, which then releases lower estrogen and increases the release of progesterone into the body. This will prepare the uterus for when the egg and sperm are ready for attachment in the uterus lining. If the egg is not fertilized, menses will begin to shed the uterine lining and another cycle will follow.

Alterations That Occur with PCOS

Polycystic Ovarian Syndrome is a multifactorial endocrine abnormality that leads to ovarian dysfunction of follicle development (Thornton et al., 2015). The follicles will mature to a certain point and then fail to release the egg into the fallopian tube. This is a reason some females with PCOS have trouble conceiving. The enlarged follicles are then considered ovarian cysts. The accumulation of cysts will eventually cause ovarian enlargement.

The specific pathophysiology of Polycystic Ovarian Syndrome is poorly understood, however, practitioners do know that it is a combination of metabolic and reproductive abnormalities (Thornton et al., 2015). Inappropriate gonadotropin secretion, chronic hyperandrogenism, and an increase in estrogen concentration are present in the typical PCOS patient. Although not present in all patients, glucose intolerance and hyperinsulinemia are strongly associated with this syndrome and may aggravate hyperandrogenic states (McCance & Huether, 2019). This occurs as insulin stimulates androgen secretion and reduces a serum globin that binds to sex hormones (SHBG), increasing testosterone levels. Insulin and excess androgens decrease apoptosis and allow the follicles to remain intact in the ovary. Further, it appears weight gain can worsen signs and symptoms of PCOS. Currently, researchers are focusing on the possibility that increased intraovarian receptors for estrogen receptor-α or insulin growth factor 1, elevated leptin levels, or direct infrared radiation within selective ovarian cells may also contribute to the development of PCOS (McCance & Huether, 2019).

Ultimately, dysfunction in the normal hormonal feedback is affected by this prolonged elevation of androgens and estrogen. There is an increase in luteinizing hormone and estradiol and may be a decrease in FSH as well. The diagram below explains how all these alterations interact with one another.

The typical patient presents with several of the following: dyslipidemia, obesity, acne, hair loss, acanthosis nigricans or discoloration in body folds, hirsutism, irregular menses, infertility, dry skin, or changes in the voice (Thornton et al., 2015).

Studies have also shown that practitioners tend to see familial traits associated with PCOS. However, the genetic cause or process remains unknown. It is reasonable to suspect that it is multifactorial and that intrauterine and childhood environments could have an impact (McCance & Huether, 2019). During a thorough reproductive history, it is important to question the patient if PCOS is present in other family members.

Key Criteria for Diagnosis

Practitioners should be aware there are several different diagnostic guidelines. The preferred guideline is Rotterdam Criteria.  This can be found in the  Diagnosis and Treatment of Polycystic Ovarian Syndrome: An Endocrine Society Clinical Practice Guideline (Thornton et al., 2015) .

Rotterdam Criteria requires two of three of the following manifestations:

• Hyperandrogenism : can be determined based on clinical observation (hirsutism + virilization) or laboratory testing (testosterone, androstenedione, or Dehydroepiandrosterone)
• Ovulatory Irregularities: important to obtain a thorough reproductive history asking about irregular menses and amenorrhea
• Polycystic Ovaries:  12(+) follicles in at least one ovary present on transvaginal ultrasound; appear as pearly white capsules when examined

This is an example of an ovary ultrasound in a PCOS patient.

Most diagnoses require ruling out many other disorders before an official diagnosis is made, especially since it cannot be confirmed with the presence of a polycystic ovary alone. It is important to note that PCOS symptoms can mimic normal changes that occur during puberty so an adolescent diagnosis requires all three of these manifestations. A practitioner should also exclude endocrinopathies that mimic PCOS in women of all ages. This can be done by testing TSH, free T4, prolactin, fasting glucose, glucose tolerance test, 17-OHP, and testosterone levels (Thornton et al., 2015).

If there is a rapid onset of these signs and symptoms it would also be important to consider an ovarian or adrenal tumor that is producing androgens. Practitioners should make patients aware that a diagnosis of PCOS can increase a female’s chance of having uterine cancer later on in life (Thornton et al., 2015).

There are many treatments practitioners may use to promote quality of life in PCOS patients. Common therapies include oral contraceptives, lifestyle modifications to decrease weight, a prescription for metformin, and possibly progesterone therapy. The main goal is to reverse the symptoms of hyperandrogenism, restoring fertility, and addressing metabolic concerns (McCance & Huether, 2019).

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ECE2017 Eposter Presentations: Reproductive Endocrinology Female Reproduction (62 abstracts)

A case of polycystic ovary syndrome (PCOS)

Kristina kljajic babic , dubravka majic milotic , kristijan peros & lea smircic duvnjak.

Clinical Hospital Merkur, Zagreb, Croatia.

: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age. It’s a heterogeneous functional disorder of unclear etiology. The features of PCOS are disorders of ovulation, androgen excess, polycystic ovaries; it’s associated with presence of associated risk factors for cardiovascular disease (obesity, glucose intolerance, dyslipidemia). The diagnosis of PCOS is made using the Rotterdam 2003 criteria. 23yo female patient was evaluated for oligomenorrhea. At the age of 17, she consulted for the first time her gynecologist because of irregluar menstrual cycles since the menarche (age 14) and excessive hair growth. A diagnosis of PCOS was made and oral contraceptives (OC) were introduced in therapy. After 1.5 yrs, OC were excluded because of undetectable levels of LH and FSH. Without them, the menstrual cycle length was 40–120 days. Examination revealed high BMI 25; normal BP; excessive hair on chin, forearms and lower abdomen; no striae, no acanthosis nigricans, normal thyroid. High levels of insulin, LH, total testosterone, androstendione and low levels of SHBG and progesterone in the luteal phase were found. An oral glucose tolerance test, fasting lipid profile and concentrations of TSH, prolactin, 17OHP were normal. A pelvic ultrasound confirmed polycystic ovaries. The clinical and lab. tests were consistent with PCOS. Therapy with life style changes (weight reduction) and metformin was started (500 mg bid). After 10 months of treatment, she lost 8 kg, menstrual cycles were regular (26–28 days), concentrations of LH, testosterone, progesterone and insulin were normal. The patients with PCOS are treated according to their symptoms, risks and desire for pregnancy. The OCs are the mainstay of pharmacologic therapy for women with PCOS for managing hyperandrogenism and menstrual dysfunction. The case has showed impact of the OC on the pituitary-ovarian suprresion. There are relatively few publications examining the effect of the OC on ovarian function in women and it’s less clear whether the pituitary–ovarian suppression induced by the OCs has any impact on functional ovarian reserve, so we need further evaluation. Although, the use of metformin in the treatment of PCOS is off-label, in this case, metformin had showed as safe and effective. Benefit was made on oligomenorrhea, fertility and obesity.

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