Polycystic Ovary Syndrome:
Definition: It is a syndrome of ovarian dysfunction, the diagnostic criteria of which include the following:
• Evidence of hyperandrogenism, biochemical or clinical(hirsutism acne & male pattern baldness).
• Ovulatory dysfunction; amenorrhoea;oligomenorrhoea.
• Morphological polycystic ovaries.
Women who have at least two of these criteria are said to have polycystic ovary syndrome. Polycystic ovaries diagnosed by ultra-sound should not be confused with PCOS. The ultrasonic picture of polycystic ovary is the presence of 10 discrete follicles of < 10 mm in diameter arranged peripherally around an enlarged central stroma.
Prevalence: PCOS affect around 5-10% of women of reproductive age group.
Aetiology:
The exact aetiology is unknown.
• Genetic factor: the syndrome clusters in families, the prevalence in first degree relatives is 5-6 times higher than in the general population.
• Hormonal factors: in those with high levels of LH there is an excess production of androgen by the ovary.
Insulin resistance occur in up to 60 % of women with PCOS especially in those with high BMI. The resultant hyperinsulinaemia stimulate LH- induced androgen production from the ovaries. In the liver elevated insulin causes a decreased production of sex-hormone binding globulin increasing the level of free androgen in the circulation.
Diagnosis:
Clinical features:
• Oligomenorrhoea/ amenorrhoea: related to chronic anovulation.
• Hirsutism.
• Subfertility.
• Obesity.
• Recurrent miscarriage.
• Acanthosis nigricance: areas of increased skin pigmentation occur in axillae & other flexures.
Laboratory test:
• Increased LH level
• Elevated LH:FSH ratio
• Elevated testosterone level
• Decreased sex hormone-binding globulin
• Increased fasting insulin level
Ultrasound: ten or more subcapsular follicular cysts <10mm in diameter with increased ovarian stroma.
Treatment:
Treatment should be directed at the symptoms that the patient complains of, as follows:
Obesity:
in obese women with PCOS significant improvement in symptoms can occur with weight reduction. However this is difficult to achieve. Change in lifestyle with altered diet & exercise might be effective.
Oligomenorrhoea/amenorrhoea:
estrogen level is normal or high, because of chronic anovulation there is unopposed estrogenic stimulation of the endometrium with the increased risk of endometrial cancer. Oligomenorrhoeic women tend to have infrequent but heavy bleeds. For these reasons, cyclical progesterone is useful to induce regular menstruation & to protect the endometrium. Oral progesterone (e.g. medroxyprogesterone acetate 10 mg daily is given for 10 days. The woman will bleed few days after the progesterone is stopped.
Alternatively for those who do not want to conceive oral contraceptive pills can be used.
Infertility:
treatment include a number of steps:
• Weight loss
• Clomiphene citrate: anti-estrogen used for ovulation induction by blocking estrogen receptors with a resultant increase in endogenous FSH production. It can be used for six months.
• Gonadotrophin therapy: recombinant FSH & human menopausal gonadotrophin are both effective for ovulation induction in those with clomiphene-resistant PCOS.
• Laparoscopic ovarian drilling: with either diathermy or laser, this can lead to normalization of LH level with increasing ovulation & pregnancy rates.
• Metformin: it has a beneficial role in reducing insulin resistance which has a central role in the pathogenesis of PCOS. Metformin may also improve menstrual regularity & improve ovarian response to clomiphene.
Hirsutism:
The aim of treatment is to reduce the androgen level, increase sex hormone-binding globulin or reduce the activity of 5?-reductase enzyme at the level of the hair follicle.
Options include:
? Oral contraceptive pills: suppress ovarian androgen production & increase sex hormone-binding globulin.
? Cyproteron acetate: an anti-androgen which competitively inhibit androgen receptors.
? Spironolactone: aldosterone antagonist with anti-androgenic properties.
? Finasteride: 5?-reductase inhibitor.
? Physical methods of hair removal: bleaching, shaving, electrolysis of hair follicle & weight loss.
Acne:
is chronic inflammation of pilosebaceous unit. Increased androgen production cause an increased size of sebaceous glands & thus increased sebum production which then become colonized with abnormal microbial flora leading to inflammation.
Acne can be treated with keratolytic agents, antimicrobials & anti-androgenic drugs.
Long-term health implications of PCOS:
include the following:
• Increased incidence of multiple pregnancy, gestational diabetes & pregnancy-induced hypertension.
• Increased incidence of type II diabetes mellitus, hypertension & hyperlipidaemia due to insulin resistance & hyperandrogenism respectively.
• Increased incidence of endometrial hyperplasia & endometrial carcinoma due to unopposed estrogen stimulation.