Polycystic Ovarian Syndrome

Key Features

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

  • Hyperandrogenism

  • 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

Clinical Findings

Symptoms and Signs

• Often presents as a menstrual disorder (from amenorrhea to heavy menstrual bleeding) 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 long-term exposure to estrogen

Differential Diagnosis

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

• Obesity

• Hypothyroidism

• Hyperprolactinemia

• Premature ovarian failure

• Cushing syndrome

• Congenital adrenal hyperplasia

• Androgen-secreting tumor (adrenal, ovarian)

• Pregnancy

Diagnosis

Laboratory Tests

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

• Fasting glucose, hemoglobin A_1C

• Lipoprotein profile

Imaging Studies

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

Treatment

Medications

• For women who are seeking pregnancy and remain anovulatory, clomiphene, letrozole, or other medications can be used for ovarian stimulation

• For women who do not respond to weight loss and exercise, combined hormonal contraceptives are first-line treatment to manage hyperandrogenism and menstrual irregularities

• Intermittent or continuous progestin therapy or a progestin-releasing IUD may be used for endometrial protection in women who cannot or chose not to use combined hormonal contraceptives

• Metformin

  • May be used as a second-line therapy to improve menstrual function

  • Has little or no benefit in the treatment of hirsutism, acne, or infertility

Therapeutic Procedures

• In obese patients, weight reduction and exercise are often effective in reversing the metabolic effects and in inducing ovulation

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

Outcome

Follow-Up

• Regular monitoring of lipid profiles and glucose

When to Refer