Polycystic Ovary Syndrome
Polycystic Ovary Syndrome: Excerpt from The 5-Minute Pediatric Consult
Ernest M. Graham, MD
Polycystic Ovary Syndrome - BASICS
Polycystic Ovary Syndrome - description
Polycystic ovary syndrome (PCOS) is an endocrinologic disorder characterized by chronic anovulation, excessive androgen production, and noncyclic gonadotropin secretion.
Polycystic Ovary Syndrome - epidemiology
PCOS is relatively common:
- Usually begins soon after menarche
Polycystic Ovary Syndrome - risk factors
Polycystic Ovary Syndrome - genetics
At least 1 group of patients with this condition inherits the disorder, possibly by means of an X-linked dominant transmission.
Polycystic Ovary Syndrome - pathophysiology
- The ovaries of most women with PCOS are enlarged as much as 5 cm in diameter, and the ovarian capsule is smooth, white, and thickened:
- Beneath the capsule are numerous small follicular cysts.
- For years, it was erroneously believed that the thick sclerotic capsule acted as a mechanical barrier to ovulation.
- Instead of the characteristic picture of fluctuating hormone levels in the normal menstrual cycle, a steady state of gonadotropin and sex steroids is produced in association with persistent anovulation.
- There is increased pulse amplitude of gonadotropin-releasing hormone (GnRH) and tonically elevated levels of luteinizing hormone (LH).
- The polycystic ovary is a sign of these underlying endocrinologic abnormalities, not a disease intrinsic to the ovary.
Polycystic Ovary Syndrome - etiology
- The characteristic polycystic ovary emerges when a state of anovulation persists for any length of time.
- Although the ovaries of these women produce excessive amounts of androgens, there is no inherent endocrinologic abnormality in the ovaries.
- The tonically elevated LH levels cause the ovarian stromal tissue to produce more androgens, which in turn produce premature follicular atresia.
- Because there are many causes of anovulation, there are many causes of polycystic ovaries.
- It has been suggested that heredity, central catecholamine abnormalities, psychological stress, insulin resistance, and obesity may be involved.
Polycystic Ovary Syndrome - DIAGNOSIS
Polycystic Ovary Syndrome - signs & symptoms
- Hirsutism
- Amenorrhea or oligomenorrhea
- Obesity
Polycystic Ovary Syndrome - history
- Complete menstrual history
- Amenorrhea or irregular vaginal bleeding
- Infertility
Polycystic Ovary Syndrome - physical exam
- Hirsutism
- Most patients with this syndrome are obese:
- Obesity probably enhances the syndrome because of the decrease in sex hormone–binding globulin, but is probably not important in its pathogenesis, because the syndrome occurs in some thin women and because many obese women do not have PCOS.
Polycystic Ovary Syndrome - tests
Polycystic Ovary Syndrome - lab
- Hormone levels:
- Because follicle-stimulating hormone (FSH) levels are normal or low, an LH/FSH ratio >3 (provided the LH level is not <8 mIU/mL) may be used to suggest the diagnosis in women with clinical features of PCOS.
- Androgen levels:
- Elevated
- Serum testosterone levels are usually between 70 and 120 ng/dL
- Androstenedione levels are usually between 3 and 5 ng/mL.
Polycystic Ovary Syndrome - differencial diagnosis
- Congenital adrenal hyperplasia
- Cushing syndrome
- Adrenal androgen-producing tumors
- Ovarian androgen-producing tumors
- Extragonadal sources of androgens
Polycystic Ovary Syndrome - TREATMENT
Polycystic Ovary Syndrome - general measures
The best treatment for PCOS is oral contraceptives, unless pregnancy is desired, because these agents inhibit LH, decrease circulating testosterone levels, and increase levels of sex hormone–binding globulin, which binds and inactivates more of the testosterone in the circulation.
Polycystic Ovary Syndrome - medication
- Use oral contraceptives that contain <50 ์g estrogen and a progestin other than norgestrel, which is the most androgenic progestin in current use.
- Patients who desire fertility should be treated with ovulation-inducing agents, starting with clomiphene citrate and proceeding to human menopausal gonadotropin or GnRH agonists if unresponsive.
- If adrenal androgens (dehydroepiandrosterones [DHEAs]) are elevated, dexamethasone (0.25–0.5 mg at bedtime) should be given with the oral contraceptive to reduce adrenal androgen levels to normal.
- Patients with amenorrhea or irregular bleeding should be treated with monthly progestins, such as oral medroxyprogesterone acetate 10 mg daily for the 1st 10 days of the month, to prevent the effects of unopposed estrogens.
- Spironolactone 50–100 mg b.i.d. causes regression of the hirsutism in women with PCOS by decreasing androgenic action in the target organs.
Polycystic Ovary Syndrome - surgery
Ovarian wedge resection was advocated in the past for treatment of androgen excess, but the decrease in circulating androgens occurred for only a short time, and this therapy should no longer be used.
Polycystic Ovary Syndrome - FOLLOW UP
In the patient who has long-standing anovulation, an endometrial biopsy, with extensive sampling, should be done because of the link between unopposed estrogen and endometrial cancer.
Polycystic Ovary Syndrome - complications
- The elevated levels of androgens that are produced are associated with hirsutism.
- The lack of a normal menstrual cycle leads to irregular bleeding, amenorrhea, and infertility.
- Because of the increased levels of unopposed estrogens, there is a 3-fold increased risk of endometrial cancer and a 3-fold greater risk of breast cancer appearing in the postmenopausal years.
Polycystic Ovary Syndrome - patient monitoring
Hormone levels
Polycystic Ovary Syndrome - bibliography
DeVane GW, Czckala NM, Judd HL, et al. Circulating gonadotrophins, estrogens, and androgens in polycystic ovarian disease. Am J Obstet Gynecol. 1975;121:496.
Dramusic V, Rajan U, Chan P, et al. Adolescent polycystic ovary syndrome. Ann N Y Acad Sciences. 1997;816:194–208.
Givens JR, Andersen RN, Wiser WI, et al. The effectiveness of two oral contraceptives in suppressing plasma androstanedione, testosterone, LH and FSH and stimulating plasma testosterone binding capacity in hirsute women. Am J Obstet Gynecol. 1976;124:333.
Goldzicher JW. Polycystic ovarian syndrome. Fertil Steril. 1981;35:371.
Goudas VT, Dumesic DA. Polycystic ovary syndrome. Endocrin Metab Clin North Am. 1997;26:893–912.
Kazar AR, Kessel B, Yen SSC. Circulating luteinizing hormone pulse frequency in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 1987;65:233.
Lobo RA, Goebelsmann U. Effect of androgen excess on inappropriate gonadotropin secretion as found in polycystic ovary syndrome. Am J Obstet Gynecol. 1982;142:394.
Polycystic Ovary Syndrome - CODES
Polycystic Ovary Syndrome - icd9
256.4 Polycystic ovary syndrome
Polycystic Ovary Syndrome - FAQ
- Q: Can I still get pregnant if I have this syndrome?
- A: Yes. Although the best treatment for this syndrome is oral contraceptives, those patients who desire to become pregnant can be treated with ovulation-inducing agents.
- Q: I’ve noticed increased facial hair recently. Is there anything I can do about this?
- A: Yes. In most cases, the oral contraceptives will decrease circulating androgen levels sufficiently so that this will regress, but if increased body hair (hirsutism) persists, another drug, called spironolactone, which blocks the action of androgens, can be added to more effectively treat this.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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