Polycystic Ovarian Syndrome (PCOS)

PCOS is the most common reproductive endocrinopathy of women during their childbearing
years, with a reported prevalence of 5-10%. It is a result of excessive ovarian androgen
production. The diagnosis is largely based on clinical history. The most distinctive and visible
clinical feature is hirsutism, usually involving the face and chin, as well as an extension of pubic
hair growth in the midline towards the umbilicus. There may be temporal balding and acne
formation as a result of androgen overproduction. Menstrual dysfunction is primarily
characterized by irregular, infrequent, or absent menstrual bleeding. Episodes of bleeding are
not typically preceded by premenstrual symptomatology. Obesity is often present, particularly
an increased waist-to-hip ratio. These women are insulin resistant and at increased risk for
diabetes. Acanthosis nigricans is common. Infertility is a common problem.

Rotterdam criteria for diagnosis of Polycystic Ovarian Syndrome (2003): (Need 2 of 3)

1. Clinical or biochemical signs of hyperandrogenism

2. Chronic Oligo- or Anovulation (<8 periods per year)
3. Polycystic ovaries seen on imaging

Note that polycystic ovaries NEED NOT be present to make the diagnosis, and their presence
alone does not establish the diagnosis.

Hormonal work-up of hyperandrogenism:

Patients suspected of having PCOS on a clinical basis should undergo a minimum endocrine
evaluation consisting of the following to rule out other conditions:

 Testosterone level
 DHEA-S
 17-hydroxy progesterone
 Prolactin
 TSH

The reason for checking testosterone and DHEA-S is to exclude the rare possibility of an
androgen-producing tumor. If those values suggest a tumor, imaging studies are warranted to
locate the lesion. Determination of 17-OHP is useful for the detection of congenital adrenal
hyperplasia caused by 21-hydroxylase deficiency. If Cushing's syndrome is a consideration, then
the 24-hour urinary free cortisol provides the most sensitive measure. Hypothyroidism and
prolactinoma should also be ruled out. Despite the widespread practice of measuring serum LH
and FSH, the circulating levels really do not contribute significantly to the diagnosis of PCOS.
The LH to FSH ratio also fails to provide additional useful information.
Medical consequences of PCOS:

Women with PCOS are insulin resistant and have compensatory hyperinsulinemia and are at high
risk for development of diabetes. This has led some to advocate checking a fasting glucose level
and a fasting insulin level in these patients. Some also check glucose tolerance tests.

Dyslipidemia is a concern given the existence of hyperandrogenemia, insulin resistance with

hyperinsulinemia, and obesity, each of which may independently exert adverse effects on lipid
metabolism. As a result, in the obese patient with PCOS, a lipid profile should be obtained.

A predisposition to macrovascular disease and thrombosis in women with PCOS has been
described. Recent studies also indicate that the prevalence of obstructive sleep apnea in PCOS is
higher than expected and cannot be explained by obesity alone. There is an increased prevalence
of endometrial hyperplasia and carcinoma in women with PCOS. Thus, clinicians should have a
high index of suspicion for ordering an overnight polysomnography test or an endometrial
biopsy if suggestive symptoms arise in a patient with PCOS.

Treatment:

Oral contraceptive pills are the predominant treatment for hirsutism and acne in PCOS. Yasmin
may be oral contraceptive of choice because of the anti-androgenic properties of drospirenone.
Spironolactone has antiandrogenic effects as well. Modest reductions in body weight through
lifestyle modification have been associated with reductions in androgen levels and improved
ovulatory function. Both metformin and thiazolidinediones have been used to reduce insulin
resistance and to induce ovulation in women desiring pregnancy.

References:

Chang RJ. A practical approach to the diagnosis of polycystic ovary syndrome. Am J Obstet
Gynecol. 2004;191:713-7.

Ehrmann DA. Polycystic Ovary Syndrome. New Engl J Med. 2005;352:1223-36.

Setji TL and Brown AJ. Polycystic ovary syndrome: diagnosis and treatment. Am J Med.
2007;120:128-132.