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Pcos (polycystic ovarian syndrome)
- 1. PCOS (Polycystic ovarian syndrome) By Umesh Nath (General Medicine)
- 2. Introduction PCOS was described first in 1935 by Stein & Leventhal. (PCOS) is a set of symptoms due to elevated androgens in females. “PCOS is a syndrome manifested by amenorrhea, hirsutism and obesity associated with enlarged polycystic ovaries.” It is the most common cause of infertility in women which is frequently seen in adolescence.
- 3. Etiology • The cause of PCOS isn't well understood, but may involve a combination of genetic and environmental factors. • Diagnosis is done on the basis of presence of any two criterias out of three. 1. Anovulation (80%) (ovaries do not release an oocyte during a menstrual cycle) 2. Hyperandrogenism 3. Polycystic ovaries (20-30%) DDx: these etologies are to be excluded. (thyroid dysfunction, hyperprolactentinaemia, cushing syndrome, CAH (congenital adrenal hyperplasia)
- 4. • Women with oligo ovulatory infertility • Obesity and/or insulin resistance • Type 1 , type 2 or gestational diabetes mellitus • A history of premature adrenarche • First-degree relatives with PCOS, it may be a manifestation of a complex genetic disorder. • Women using antiepileptic drugs. High risk groups
- 5. Clinical features • Increasing obesity(abdominal-50%) • Menstrual abnormalities (70%): oligomenorrhea, amenorrhea, infertility & DUB (Dysfunctional uterine bleeding). • Hirsutism (presence of body hair pattern like male & acnes present in about 70% (most important features) • Virilism (increasing androgen cause development of male sexual characters), it's very rare. • Hair-An syndrome : hyperandrogenism, insulin resistance and acanthosis nigricans, internal examination reveals bilateral enlarged cystic ovaries. Mayn't be revealed due to obesity
- 6. Investigation • Transvaginal Sonography is useful specially in obese patients. ovaries are enlarged in volume (>10cm³), increased number(>12) of peripherally arranged cysts (2- 9) are seen. • Serum values LH level elevated and/or the ratio LH:FSH is >2:1 Raised estradiol & estrone : estronrle is markedly elevated. SHBG level is reduced. Raised serum testosterone (>150ng/dL) • Insulin resistant (IR): Raised fasting insulin levels >25μIU/mL
- 7. Investigation Fasting glucose/insulin ratio <4.5. suggests IR (insulin resistance) 50% • Laparoscopy : bilateral polycystic ovaries are charecteristics of PCOS.
- 8. Sequelae (symptoms) of PCOS Short term • Obesity • Menstrual disorders • Anovulation, infertility • Miscarriage • Abnormal lipid profile • Androgen excess Acne Hirsutism Alopecia (Hair loss) • Insulin resistance Acanthosis nigricans Glucose intolerance • Long term • Diabetes mellitus • Endometrial cancer • Hypertension • Cardiovascular disease • Atherosclerosis • Obstruction sleep apnea • Dyslipidemia (Dyslipidemia is an abnormal amount of lipids )
- 9. Management The primary treatments for PCOS include: lifestyle changes and medications to correct biochemical abnormalities. Goals of treatment may be considered under four categories: • Lowering of insulin resistance levels • Restoration of fertility • Treatment of hirsutism or acne • Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer.
- 10. Management 1. Weight reduction BMI <25 improves menstrual disorders, infertility, impaired blood glucose intolerance (Insulin resistance) , hyperandrogenemia (hirsutism, acne) & obesity. Weight reduction (2-5%) improves the metabolic syndrome & reproductive function. 2. Fertility not desired * Management of Hyperandrogenemia Combined Oral contraceptive pills Use of antiandrogens * Metabolic syndrome Hyperinsulinemia(IR), causes Hyperandrogenemia.
- 11. Management *endometrial hyperplasia Combined oral contraceptives to prevent hyperplasia & abnormal bleeding. 3. Patient desires pregnancy • Improve metabolic syndrome to prevent chronic anovulation, which is most common cause of infertility. • Ovulation induction is achieved by clomiphene citrate following correction of other biochemical abnormalities. • Insulin sensitizers: women with PCOS & hyperinsulinemia with BMI>25, ovulate satisfactorily when clomiphene is combined metformin.
- 12. Management 4. Surgery: laproscopic ovarian drilling (LOD) is done for cases found resistant to medical therapy. It has replaced with the conventional wedge resection of the ovaries. Bariatric surgery may be indicated in some PCOS women who're morbidly obese. Thank You Lets connect on different social medias (Umesh Nath)