Brief Summary of Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders.These patients have a steady state of relatively high estrogen, androgen and LH levels rather than the fluctuating levels seen in ovulating women.

Definition
There are two definitions or diagnostic criteria that are commonly used:

 - In 1990 a consensus workshop sponsored by the NIH(National Institutes of Health)/NICHD(National Institute of Child Health and Human Disease) suggested that a patient has PCOS if she has all of the following:

• Oligoovulation
• Signs of androgen excess (clinical or biochemical)
• Other entities are excluded that can result in menstrual irregularity and hyperandrogenism.

 - In 2003 a consensus workshop sponsored by ESHRE(European Society for Human Reproduction and Embryology)/ASRM(American Society for Reproductive Medicine) in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met.

• Oligoovulation and/or anovualation manifested as oligomenorrhea or amenorrhea
• Excess androgen activity (clinical or biochemical evidence)
• polycystic ovaries (as seen on gynecologic ultrasound)

Pathophysiology
Increased level of estrogen comes from obesity due to conversion of ovarian and adrenal androgen to estrone in body fat. High estrogen level suppresses FSH and causes relative increase in LH. Constant LH stimulation of ovary results in anovulation, multiple cysts and theca cell hyperplasia with excess androgen production.

Clinical PresentationA patient with polycystic ovary syndrome presents with following clinical features:

• Hirsutism (male pattern of hair growth).
• Obesity
• Virilization (development of male-like characteristics).
• Amenorrhea (no menstrual periods).
• Abnormal uterine bleeding.
• Insulin resistance and hyperinsulinemia with increased risk of type II diabetes.
• Infertility (This generally results directly from lack of ovulation)
• Increased risk of cancer of breast and endometrium due to unopposed estrogen production. 

Workup
The diagnosis of polycystic ovarian syndrome (PCOS) requires the exclusion of all other disorders that can result in menstrual irregularity and hyperandrogenism, including adrenal or ovarian tumors. Biochemical and/or imaging studies must be done to rule out these other possible disorders and ascertain the diagnosis. A karyotype usually excludes mosaic Turner syndrome as a cause of the primary amenorrhea.

• LH to FSH ratio is >2.5: 1.
• There is increased androgens (testosterone and dehydroepiandrosterone)
• A small percentage of patients have elevated prolactin levels (typically >25 mg/dL).

Histology
Histological changes of the ovary include enlarged, sclerotic, multiple cystic follicles.

Management

1. Weight reduction: To lower the conversion of androgen to estrogen to restore ovulation.

2. Infertility Management: If the patient desires pregnancy give clomiphene plus dexamethasone for ovulation. Sometimes metphormin 500mg three times daily is given if the patient does not respond to clomiphene and dexamethasone

3. If pregnancy is not desired, medroxyprogesterone acetate 10mg/day for the first 10 days of the month should be given to ensure regular shedding of endometrium so that hyperplasia will not occur.

4. Hirsutism management: Spironolactone, dexamethasone, eplication or electrolysis.