Polycystic ovaries

1
Polycystic ovaries

• Mrs K Reddy
• Consultant Gynaecologist
• July 2008

2
PCOS

• ASRM/ESHRE definition - Rotherdam Criteria 2003
• presence of two out of three criteria
• oligo and or anovulation
• hyperandrogenism( clinical and or biochemical)
• polycystic ovaries
• with the exclusion of other etiologies
• MORPHOLOGY has been redefined
• - ovary with 12 or more follicles ( 2-9mm) and
  or increased ovarian volume(gt10cubic cm) -
  distribution and description of stroma not
  required

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PCOS

• Asymptomatic polycystic ovaries
• polycystic ovaries in the absence of anovulation
  or hyperandrogenism
• she may develop symptoms over time if she gains
  weight
• Polycystic ovarian syndrome
• - the criteria when applies

4
PCOS - Investigations
5
PCOS

• Metformin is no longer recommended as the first
  line of management for infertility

6
Indications for Metformin therapy

• Empirical therapy may improve symptoms of
  hyperandrogenism and menstrual irregularity.
• Weight loss is not guaranteed. Diet and exercise
  are essential. Antiobesity drugs or surgery may
  be indicated.
• Side effects are GI - can be reduced by taking
  with food
• Not thought to cause lactic acidosis in non
  diabetic women with PCOS and normal liver and
  renal function
• May be continued long term.
• Used in Clomid resistant patients - infertility

7
Clomifene vs. metformin for fertility
Legro et al. NEJM 2007
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Key Points

• Commonest endocrine disorder in women (
  prevalence 15-20)
• Need to use the criteria to make a diagnosis
• Management is symptom oriented
• If obese weight loss improves symptoms. GTT
  should be performed if BMI gt30
• Menstrual cycle control is achieved by OC Pill,
  progestrogens or metformin
• Ovulation induction may be difficult and require
  careful monitoring
• Hyperandrogenism is usually managed with Dianette
  or Yasmin. Other therapies are Finesteride,
  spiranolactone, metformin or vaniqua cream or a
  combination of treatment.
• Metformin is no longer the first line of
  treatment for infertility in PCOS. Better to be
  prescribed after recommendation by
  endocrinologists/reproductive specialists

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Case Scenarios

• 30 yr old with 1year history of irregular cycles
  and trying to conceive.
• 35year old having only 3 cycles in a year. Weight
  15 stone. Fertility not an issue. Hirsuitism
  Scan was normal.

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Case Scenarios

• 27year old with regular cycles, normal BMI.
  Investigations revealed raised prolactin of 980.
  Repeat still raised. Infertility for 2 years.
• 25 year old with BMI 35, has had only 3-4 cycles
  since menarche aged 14. Investigations LH/FSH -
  26/4, testosterone of 3.6. Scan revealed PCOS
  with ET of 4mm. no withdrawl bleed with provera.
  Fertility is an issue.