Polycystic Ovarian Syndrome

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Polycystic Ovarian Syndrome Hirsutism

• Walter Eisenhauer MMSc, PA-C

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Polycystic Ovarian Syndrome

• Formerly called Stein Leventhal Syndrome (1905)
• Characterized by
• anovulatory bleeding/amenorrhea
• hirsutism,
• obesity,
• hyperinsulinemia/insulin resistance,
• bilateral ovarian enlargement multiple cysts
• Infertility
• Hyperandrogenemia Hyperestrogenemia (due to
  peripheral conversion)

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Polycystic Ovarian Syndrome

• Patients are obese and manifest insulin
  resistance- frank diabetes is rare
• Infertility75 of cases
• Hirsutism70 of cases
• Amenorrhea50 of cases

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Polycystic Ovarian Syndrome

• Pathophysiology
• incompletely understood
• abnormally elevated LH levels
• loss of mid cycle LH surge
• Excessive androgen production
• Atresia of ovarian follicles
• Ratio of LHFSH markedly increased

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Polycystic Ovarian Syndrome

• Inciting events are unknown and may differ from
  one person to the next
• Disturbance in hypothalamic-pituitary function is
  postulated
• Hyperinsulinism hyperandrogenism appear related
  but incompletely defined

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Polycystic Ovarian Syndrome

• Affects 5 of reproductive age women
• Represents a leading cause of chronic anovulatory
  bleeding
• disorder of hypothalamic rhythmicity
• excessive LH production without mid cycle surge
• leads to overproduction of testosterone
  Androstenedione

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Polycystic Ovarian Syndrome

• Androgens converted to estrone which causes
  endometrial proliferation that results in
  irregular periods
• Serum concentrations of both estrogen and
  testosterone rise
• Insulin resistance once believed to be due to
  ovarian androgen overproduction
• Current theory is that Hyperinsulinism causes
  ovarian androgen overproduction

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Polycystic Ovarian Syndrome

• Consequence of androgen overproduction
• hirsutism
• frank virilization
• Chronic unopposed estrogen stimulation leads to
  endometrial Hyperplasia, cellular atypia, and
  endometrial carcinoma

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Polycystic Ovarian Syndrome

• Risk of endometrial carcinoma increased threefold

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Polycystic Ovarian Syndrome

• History
• Complete a good menstrual history
• menarche
• duration, frequency, intensity of bleeding
• periods always irregular or new onset
• menorrhagia/metrorrhagia
• Sx of pregnancy
• Attempt to determine if irregular bleeding
  ovulatory or anovulatory

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Polycystic Ovarian Syndrome

• History
• Ovulatory bleeding suggested by presence of
  premenstrual symptoms
• breast engorgement
• pelvic cramping
• fluid retention
• mood swings
• Menstrual regularity more suggestive of ovulatory
• Family Hx of PCO

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Polycystic Ovarian Syndrome

• Anovulatory
• absence of premenstrual symptoms
• frequently long periods of amenorrhea followed by
  irregular bleeding

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Polycystic Ovarian Syndrome

• If bleeding thought to be anovulatory ask the
  following
• precipitated by emotional stress?
• Recent weight loss?
• Exercise?
• chronic illness?
• Rapid onset of hirsutism and virilization
  suggestive of adrenal or ovarian tumor secreting
  androgens

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Polycystic Ovarian Syndrome

• Life long history of irregular menses, hirsutism,
  infertility, and obesity is suggestive of PCO

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Polycystic Ovarian Syndrome

• Physical Examination
• General
• seek s/s of virilization
• Skin
• changes suggestive of thyroid disorders
• Hair
• Neuro
• Pituitary tumors may cause bitemporal
  hemianopsia, headaches other focal neuro findings

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Polycystic Ovarian Syndrome

• Pelvic
• ovarian enlargement-irregularity suggestive of
  cysts
• clitoral hypertrophy
• Breasts
• Galactorrhea
• Suggestive of hyperprolactinemia

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Polycystic Ovarian Syndrome

• Laboratory testing(the following may be elevated
  and the only chemical evidence supporting PCO)
• Estrone
• Androstenedione
• Free testosterone
• Pelvic Ultrasound
• use to detect polycystic ovaries

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Polycystic Ovarian Syndrome

• Two hour post prandial glucose
• Lipid studies

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Polycystic Ovarian Syndrome

• Treatment
• Reduce risk of endometrial cancer by
  administering monthly/bimonthly course of
  medroxyprogesterone to induce menstrual bleeding
• Infertility
• Old therapy wedge resection of ovaries (only
  brings short term relief)
• Still used

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Polycystic Ovarian Syndrome

• Treatment
• Infertility
• Clomiphene
• Prednisone
• Oral contraceptives
• spironolactone
• Hyperinsulinemia
• weight loss
• exercise
• oral hypoglycemics

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Hirsutism

• Definition
• Increase in transformation from vellus to
  terminal hair
• Dont confuse with Non androgen dependent
  increase in hair known as
• Familial hypertrichosis
• vellus hair only
• face and trunk
• Managed by mechanical hair removal only

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Normal Hair Growth

• Hair grows cyclically not continuously
• Anagen-rapid growth
• Catagen-involution
• Telogen- resting stage

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Hirsutism

• Androgen dependent
• Male pattern hair growth
• respond best to combination therapy(hair removal
  and meds)
• 95 have both adrenal and ovarian causes
• PCO most common

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Hirsutism

• Causes of hirsutism
• Adrenal tumors
• Congenital adrenal hyperplasia
• Cushing's syndrome
• Medications (eg, Cyclosporine, anabolic steroids)
  
• Ovarian tumors
• Polycystic ovary syndrome
• Racial or ethnic background

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Hirsutism

• History
• Menstrual
• Family history
• Meds
• Endocrine review of systems

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Hirsutism

• Physical Examination
• General
• Endocrine
• Abdomen
• Pelvic
• Skin

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Hirsutism

• Lab evaluation
• Testosterone levels
• DHEA
• 24 hour free cortisol/dex suppression test
• Imaging studies of ovaries/adrenals

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Hirsutism

• Guidelines for the Treatment of Hirsutism
• Polycystic ovary syndrome
• Oral contraceptives (Demulen 1/35, Desogen,
• Ortho-Cept, Ortho-Cyclen or Ortho Tri-Cyclen)
• Spironolactone (Aldactone), 50 to 100 mg two
  times per day

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Hirsutism

• Idiopathic
• Oral contraceptives
• (Demulen 1/35, Desogen, Ortho-Cept, Ortho-Cyclen
  or Ortho Tri-Cyclen)
• Spironolactone, 50 to 100 mg two times per day
• Nonclassic
• Glucocorticoids prednisone, 5 mg every night
• Congenital adrenal hyperplasia
• dexamethasone, 0.25 mg every night at bedtime
• Cushing's syndrome
• Surgical excision of ACTH-secreting pituitary

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Hirsutism

• adenoma or ectopic ACTH-secreting tumor
• adrenalectomy for adrenal hyperplasia
• Adrenal tumor
• Surgical excision
• Ovarian tumor
• Surgical excision
• Drug-induced
• Discontinue medication

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Hirsutism

• Polycystic ovary syndrome
• Finasteride (Proscar), 5 mg per day, GnRH
  agonist (Lupron Depot), 3.75 mg monthly
• Idiopathic
• Finasteride, 5 mg per day