Polycystic Ovary Syndrome (Persistent Anovulation)

Essentials of Diagnosis

• Clinical or biochemical evidence of hyperandrogenism

• Anovulation or oligoovulation

• Polycystic ovaries on ultrasonography

General Considerations

• Etiology is unknown

• Presence of at least two of the following features outlined by the Rotterdam Criteria are diagnostic

  • Androgen production

  • Ovulatory dysfunction

  • Polycystic ovaries

• Associated with hirsutism, obesity as well as an increased risk of diabetes mellitus, cardiovascular disease, and metabolic syndrome

• Unrecognized or untreated PCOS is a risk factor for cardiovascular disease

Demographics

• Affects 5–10% of women of reproductive age

Symptoms and Signs

• Often presents as a menstrual disorder (from amenorrhea to menorrhagia) and infertility

• Skin disorders due to peripheral androgen excess, including hirsutism or acne, are common

• Patients may show signs of insulin resistance and hyperinsulinemia; these women are at increased risk for early-onset type 2 diabetes and metabolic syndrome

• Patients who do become pregnant are at increased risk for perinatal complications, such as gestational diabetes and preeclampsia

• In addition, they have an increased long-term risk of endometrial cancer secondary to unopposed estrogen secretion

Differential Diagnosis

• Hypothalamic amenorrhea, eg, stress, weight change, exercise

• Obesity

• Hyperthyroidism or hypothyroidism

• Hyperprolactinemia

• Premature ovarian failure

• Cushing syndrome

• Congenital adrenal hyperplasia

• Androgen-secreting tumor (adrenal, ovarian)

• Pregnancy

Laboratory Tests

• Check serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH)

• Fasting glucose test, hemoglobin A_1C

• Lipoprotein profile

• Women with signs of Cushing syndrome should have a 24-hour urinary free cortisol or a low-dose dexamethasone suppression test

Imaging Studies

• Pelvic ultrasound may document polycystic ovaries (not necessary for diagnosis)

Medications

• If the patient wishes to become pregnant

  • Clomiphene or other drugs can be used for ovarian stimulation

  • Clomiphene is the first-line therapy for infertility

  • Metformin can improve menstruation but has little or no benefit in treating infertility; it is beneficial for metabolic or glucose abnormalities

• If the patient does not desire pregnancy

  • Medroxyprogesterone acetate, 10 mg daily orally for the first 10 days of every 1–3 months

  • If contraception is desired, a combination hormonal contraceptive (pill, ring, or patch) can be used

• The levonorgestrel-containing IUD

  • Another option to minimize uterine bleeding and protect against endometrial hyperplasia

  • However, the IUD does not help control hirsutism

• Hirsutism

  • A low-dose combination oral contraceptive for at least 6–12 months

  • Spironolactone is also useful in doses of 25 mg three or four times daily orally

  • Flutamide, 125–250 mg once daily orally, and finasteride, 5 mg once daily orally, are also effective

  • Because spironolactone, flutamide, and finasteride are potentially teratogenic, they should only be used with secure contraception

  • Topical eflornithine cream applied to affected facial areas twice daily for 6 months may be helpful

Therapeutic Procedures

• In obese patients with polycystic ovaries, weight reduction is often effective; a decrease in body fat will lower the conversion of androgens to estrone and thereby help restore ovulation

• Hirsutism may be managed with depilatory creams, electrolysis, and laser therapy

Prognosis

• Women have insulin resistance and hyperinsulinemia when infused with glucose and are at increased risk for early-onset type 2 diabetes mellitus

• Women have an increased long-term risk of cancer of the endometrium because of unopposed estrogen secretion

When to Refer

• If expertise in diagnosis is needed

• If the patient is having infertility problems