Polycystic ovary syndrome is a clinical syndrome characterized by mild obesity, irregular menses or amenorrhea, and signs of androgen excess (eg, hirsutism, acne). Most patients have multiple cysts on the ovaries. To reach the diagnosis, a pregnancy test, blood hormone determination, and imaging studies must be performed to exclude the presence of a virilizing tumour. Treatment is symptomatic.
Polycystic ovary syndrome (PCOS) occurs in 5-10% of women. In the United States, it is the most common cause of infertility.
In general, PCOS is defined as a clinical syndrome, not due to the presence of ovarian cysts. But generally, the ovaries contain several 2-6 mm follicular cysts and sometimes large cysts with atresia cells. The ovaries may be enlarged, with thickened capsules, or they may be normal in size.
This syndrome involves anovulatory or ovulatory dysfunction and an excess of androgens of an Etiology not yet completely known. However, some evidence suggests that patients have a functional abnormality of cytochrome P450c17 that affects 17-hydroxylase (the rate-limiting enzyme in androgen production); as a result, androgen production increases.
Polycystic Ovary Syndrome Complications
Polycystic ovary syndrome has several serious complications.
Estrogen levels are elevated, increasing the risk of endometrial hyperplasia and eventually endometrial cancer.
Androgen levels are often elevated, increasing the risk of metabolic syndrome and causing hirsutism. Hyperinsulinemia due to insulin resistance may be present and contribute to increased ovarian androgen production. In the long term, excess androgen increases the risk of cardiovascular disorders, including hypertension and hyperlipidemia. The risk of excess androgen and its complications can be as high in women who are not overweight as in those who are overweight.
Polycystic Ovary Syndrome Signs and symptoms
Polycystic ovary syndrome symptoms begin during puberty and worsen over time. Premature adrenarche, characterized by excess dehydroepiandrosterone sulfate (DHEAS) and frequently, often early growth of axillary hair, presence of body odour, and acne with >Microcomedones.
Typical symptoms include mild obesity, slight hirsutism, and irregular menses or amenorrhea. However, up to half of the women with polycystic ovary syndrome are normal weight, and some women are underweight. Body hair may grow in a masculine pattern (eg, on the upper lip, chin, back, thumbs and toes; around the nipples, and along the alba line of the underside abdomen). Some women show other signs of virilization, such as acne and decreased hair in the temporal region.
Other symptoms may include weight gain (sometimes seem difficult to control), fatigue, lack of energy, sleep-related problems (including sleep apnea), mood swings, depression, anxiety, and headaches. In some women, fertility is affected. Symptoms vary from woman to woman.
Areas of darkened and thickened skin (acanthosis nigricans) may appear in the armpits, nape of the neck, in the pleated regions and on the knuckles and/or elbows; the cause is elevated insulin levels due to insulin resistance.
Acanthosis nigricans in polycystic ovary syndrome
If women with PCOS become pregnant, the risk of complications during pregnancy increases, and complications are worse if women are obese. These complications include gestational diabetes, premature delivery, and preeclampsia.
Polycystic Ovary Syndrome Diagnosis
- Clinical criteria
- Serum levels of testosterone, follicle-stimulating hormone, prolactin, and thyrotrophin should be evaluated.
- Pelvic ultrasound
In general, there is ovulatory dysfunction at puberty, leading to primary amenorrhea; therefore, this syndrome is unlikely if there were regular menses at any time after menarche.
On physical examination, abundant cervical mucus is generally found, reflecting high estrogen levels. PCOS should be suspected in women with at least two typical symptoms.
Studies include pregnancy tests, assessment of total serum levels of testosterone, follicle-stimulating hormone (FSH), prolactin, and thyrotrophin (TSH); and pelvic ultrasound to exclude other possible causes of symptoms. The testosterone – free is more sensitive than total levels of testosterone but is technically more difficult to measure. Levels of testosterone normal slightly increased FSH and normal to slightly decreased suggest SOP.
Diagnosis requires at least 2 of the following 3 criteria:
- Ovulatory dysfunction that causes menstrual irregularity
- Clinical or biochemical evidence of hyperandrogenism
- > 10 follicles per ovary (detected by pelvic ultrasound), generally on the periphery and simulating a pearl necklace
In women who meet these criteria, serum cortisol levels are measured to exclude Cushing syndrome, and serum 17-hydroxyprogesterone level is measured early in the morning to exclude adrenal virilization. DHEAS is measured in serum. If DHEAS is normal, amenorrhea should be sought.
In adult women with PCOS, a metabolic syndrome should be sought by measuring blood pressure and usually blood glucose and lipids (lipid profile).
Pearls and mistakes
PCOS is unlikely if there were regular menses for a time after menarche.
Polycystic Ovary Syndrome Treatment
- Intermittent progestogens or oral contraceptives
- Management of hirsutism and, in adult women, the risks of long-term hormonal disturbances.
- Management of infertility in women who want to become pregnant
- Treatment aims
- Correct hormonal abnormalities and thus reduce the risks of excess estrogen (eg, endometrial hyperplasia) and excess androgen (eg, cardiovascular disorders).
- Relieve symptoms and improve fertility
Weight loss and regular exercise should be encouraged. They can help induce ovulation, regularize cycles, increase insulin sensitivity, and reduce acanthosis nigricans and hirsutism. Weight loss can also help improve fertility. However, weight loss is unlikely to benefit women of normal weight with PCOS.
Hormonal contraceptives are the first-line therapy for menstrual abnormalities, hirsutism, and acne in women who have PCOS and who do not want a pregnancy. Women are generally treated with an intermittent progestogen (eg, medroxyprogesterone 5-10 mg orally once / day for 10-14 days every 1-2 months) or oral contraceptives to reduce the risk of endometrial hyperplasia and cancer. These treatments also reduce circulating androgens and generally help regularize menstrual cycles.
500 to 1,000 mg of metformin twice daily is used to help increase insulin sensitivity in women with PCOS, irregular menstruation, and diabetes or insulin resistance if lifestyle modifications are not effective or if they cannot tolerate hormonal contraceptives. Metformin can also lower testosterone levels free. When metformin is used, glucose should be monitored, and kidney and liver functions should also be regularly evaluated. Since metformin can induce ovulation, a contraceptive regimen is required if a pregnancy is not desired. Metformin helps correct metabolic and glycemic abnormalities and makes menstrual cycles more regular, but it has little or no beneficial effect on hirsutism, acne, or sterility.
Women who do not want pregnancy are usually treated with an intermittent progestogen (eg, medroxyprogesterone 5-10 mg orally once / day for 10-14 days every 1-2 months) or oral contraceptives to reduce risk of endometrial hyperplasia and cancer. These treatments also reduce circulating androgens and generally help regularize menstrual cycles.
For women who want to get pregnant, infertility treatments (eg, clomiphene) are used. Clomiphene is currently the first-line therapy for infertility. Weight loss can also be helpful. Hormone therapy that may have contraceptive effects should be avoided. Women with PCOS are at increased risk for complications in pregnancy, including gestational diabetes, preterm labour, and preeclampsia, which are exacerbated by obesity. Preconception evaluation of body mass index (BMI), BP, and oral glucose tolerance is recommended.
For hirsutism, physical measures (eg, whitening, electrolysis, waxing, or waxing) can be used. Cream with 13.9% eflornithine 2 times a day can help remove undesirable facial hair. In adult women who do not want to become pregnant, hormone therapy that lowers androgen or spironolactone levels can be used.
The acne can be treated with usual medications (p. G., Benzoyl peroxide, tretinoin cream, topical antibiotics and oral).
Treatment of Comorbidities
Because PCOS increases the risk of depression and anxiety, adult women and adolescents with PCOS should be screened for these problems based on the history and, if a problem is identified, should be referred to professional mental health or treated as needed.
Teenagers who are overweight or obese and women with PCOS should undergo screening for symptoms of obstructive sleep apnea using polysomnography and treated as needed.
Because PCOS can increase the risk of cardiovascular disorders, women with PCOS and any of the following should be referred to a cardiovascular specialist for the prevention of cardiovascular disorders:
- Family history of early-onset cardiovascular disorders
- Mellitus diabetes
- Sleep apnea
- Abdominal obesity
Women with abnormal vaginal bleeding should undergo endometrial carcinoma screening by endometrial biopsy and / or transvaginal ultrasound or ambulatory hysteroscopy.
- PCOS is a common cause of ovulatory dysfunction.
- Suspect PCOS in women who have irregular periods are slightly obese and a little hirsute, but be aware that the weight is normal or low in many women with PCOS.
- Studies for severe disorders (eg, Cushing’s syndrome, tumours) that can cause similar symptoms and for complications (eg, metabolic syndrome)
- If the woman does not want pregnancy, she is treated with hormonal contraceptives and lifestyle modifications are recommended; if lifestyle modifications are not effective, metformin is added.
- Examine comorbidities, such as endometrial cancer, mood and anxiety disorders, obstructive sleep apnea, diabetes, and cardiovascular risk factors (including hypertension and hyperlipidemia).