Polycystic Ovary Syndrome

1
Polycystic Ovary Syndrome

• Lianne Beck, MD
• Assistant Professor
• Emory Family Medicine

2
Overview

• Prevalence and Pathogenesis
• Signs and Symptoms
• Diagnosis
• Treatment

3
Background

• Stein Leventhal 1935
• Amenorrhea
• Infertility
• Hirsutism
• Enlarged polycystic ovaries

4
Prevalence

• Most common hormonal and reproductive problem
  affecting women of child-bearing age
• Present in 5-10 of women
• Commonly under-diagnosed due to use of birth
  control pills

5
Pathogenesis

• UNKNOWN
• High insulin levels
• High androgen levels
• High LH
• Low estro/prog

6
Pathogenesis

• Genetics
• Insulin-receptor substrate (IRS-1,IRS-2)
• Calpain-5
• Calpain-10

7
Signs and Symptoms

• Pre-puberty
• Increased levels of adrenal androgen
• Increased insulin levels
• Ovarian hyperandrogenism
• Leads to precocious puberty

8
Signs and Symptoms

• Adolescence and Adulthood
• Anovulation
• Hyperandrogenism
• Polycystic ovaries
• Obesity-50 of women
• Leads to reproductive disorders

9
Signs and Symptoms

• Late Adulthood
• Diabetes
• Hypertension
• Dyslipidemia
• Cardiovascular disease
• Leads to metabolic effects

10
Other Complications

• Endometrial Cancer
• Breast Cancer

11
Clinical Features

• Acne
• Hirsutism

12
Clinical Features

• Acanthosis nigricans
• Skin tags

13
Clinical Features

• Male-pattern alopecia
• Central obesity

14
Diagnostic Criteria

• 1990 NIH criteria (all 3 must be met)
• Hyperandrogenism, either clinical or biochemical
• Menstrual irregularity (oligo- or anovulation)
• Exclusion of other causes
• Prolactinoma
• Thyroid disease
• Virilizing tumors of adrenal or ovarian tumors
• Congenital adrenal hyperplasia
• Cushing's syndrome

15
Revised Diagnostic Criteria

• 2003 Rotterdam Criteria
• Presence of at least two of the following
• Oligo/anovulation
• Hyperandrogenism
• Polycystic ovaries on ultrasound
• And the exclusion of other causes

16
PCOS and Associated Lab Findings

• Laboratory tests
• Elevated androgen (i.e., testosterone) levels
• Elevated LH with normal to mildly elevated FSH
  level
• Insulin resistance with hyperinsulinemia
• Glucose intolerance
• Hyperlipidemia
• Ultrasound findings
• Multiple (nine or more) subcortical follicular
  cysts
• Increased ovarian stromal density and/or volume

17
Sonogram of PCOS
The sonogram has a compact enlarged central
stroma surrounded by multiple ( 12 or more) small
cysts, of 2 to 9 mm in size.
18
Suggested Work-up of PCOS

• Urine HCG
• Prolactin level
• TSH
• Testosterone
• LH/FSH (31)
• Fasting insulin
• Fasting glucose, 2 hr GTT
• Fasting lipids

• Pelvic US
• DHEAS
• 17-OHP
• Dexamethasone suppression test
• Endometrial biopsy

--Suggested only in selected patients.
19
Goals of Treatment

• Decrease hyperinsulinism
• Decrease hyperandrogenism
• Induce ovulation
• Prevent endometrial hyperplasia
• Prevent metabolic complications
• Weight loss

20
Behavior Modification

• Weight reduction
• Diet and exercise
• Decreases serum androgen, insulin and LH levels
  and improves lipid abnormalities

21
First-Line Medications
22
Second-Line Medications
23
Patient Support

• www.soulcysters.com
• www.pcos.meetup.com
• www.pcosupport.org

24
(No Transcript)
25
(No Transcript)
26
Quiz

• Which one of the following drugs occasionally
  used to treat hirsutism in polycystic ovary
  syndrome (PCOS) is U.S Food and Drug
  Administration pregnancy category X?
• A. Spironolactone (Aldactone)
• B. Metformin (Glucophage)
• C. Finasteride (Propecia)
• D. Flutamide (formerly Eulexin)

27

• Which one of the following drugs has the most
  data supporting its effectiveness in treating
  most manifestations of PCOS?
• A. Rosiglitazone (Avandia)
• B. Metformin
• C. Clomiphene (Clomid)
• D. Spironolactone

28
Questions?
29
References

• American Journal of Gynecology. 1998. Dec179 (6
  Pt 2) S101
• Hunter MH. Sterrit JJ. Am Fam Phys 2000, vol. 62,
  no. 5
• Norman RJ. Wu R. Stankiewicz MT. Polycystic Ovary
  Syndrome. MJA 2004 180 (3) 132-137.
• Marrinan G. Stein M. Polycystic Ovarian Disease
  (Stein-Leventhal Syndrome. E-Medicine, May 24,
  2005.
• Radosh L. Drug Treatments for Polycystic Ovarian
  Syndrome. Am Fam Phys 2009, vol. 79, no. 8