1. PCOS Abdalmohsenababtain October 2010

2. Objectives Definition Epidemiology Normal physiology Pathophysiology Diagnostic criteria Presentation Investigations Management

3. Definition NIH (1990): chronic, unexplained hyperandrogenism and evidence of anovulation It Is a Syndrome associated with a range of metabolic abnormalities which can lead to long term health problems

4. Epidemiology Prevalence: 6-10% females of reproductive age the most common endocrine disorder among young women

5. Normal physiology

6. Normal physiology

7. Pathogenesis The Exact mechanism is not clear yet . Intraovarian androgen excess appears to be responsible for both anovulation and formation of multiple ovarian cysts. This could be caused by DisturpedGnRH secretion OR ovarian or adrenal excess steroidogenesis

8. Genetics and PCOS PCOS is a familial disorder, but its genetic basis remains controversial. A study reported that 46% of sister PCOS patients have some features of PCOS. A study of 150 subjects with PCOS showed evidence of an autosomal dominant inheritance

9. Abnormal gonadotropin secretion Excess LH and low FSH Hypersecretion of androgens Disrupts follicle maturation Substrate for peripheral aromatization  more estrogen Negative feedback on pituitary Decreased FSH secreation Insulin resistance, Elevated insulin levels High LH  high androgen level from thecal cell

10. Final result : arrested growth of the follicles at a diameter of 5–8mm i.e. well before a mature follicle would be expected to ovulate

12. Diagnostic criteria Rotterdam criteria(2 out of 3) : Unexplained hyperandrogenism Oligo or anovulation Polycystic ovaries (added 2003) History-taking, specifically for menstrual pattern, obesity, hirsutism, and the absence of breast development, can diagnose PCOS with a sensitivity of 77.1% and a specificity of 93.8% NIH 1990

13. AES(Androgen Excess Society) criteria 2006 Hyperandrogenism, preferably confirmed by biochemical testing Evidence of ovarian dysfunction(Oligo, anovulationor Polycystic ovaries )

15. presentation Polycystic ovaries (80%) Anovulatory bleeding (80%) Anovulatory infertility (75%) Hirsutism (70%) Overweight or obesity (50%) Premature pubarche, and/or precocious puberty DUB Acne Male-pattern hair loss Acanthosisnigricans

16. PCOS Features Cutaneous : hirsutism, acne or acanthosisnigricans, male-pattern alopecia, seborrhea and hyperhidrosis Anovulatory : include amenorrhea, oligomenorrhea, dysfunctional uterine bleeding, ploycystic ovaries and infertility General : Obesity, Metabolic syndrome and Insulin Resistance

18. Hirsutism and PCOS Acne vulgaris, pattern alopecia, seborrhea, hyperhidrosis, and hidradenitissuppurativa are considered to be hirsutism equivalents Hirsutism defined as coarse terminal hair in a male distribution do not confuse with lanugo hair assessed by the Ferriman-Gallwey score if >8  excess androgen does not always correlate with androgen levels

20. PCOS was the cause of hirsutism in (82%) of a study done to determine the clinical, biochemical and etiologic features of hirsutism in Saudi females

22. infrequent periods ( > 35 day cycle)

24. Metabolic syndrome & PCOS PCOS is also associated with a characteristic metabolic syndrome that includes: insulin resistance dyslipidemia hypertension These features are linked with increased risks of type 2 diabetes and possibility of premature cardiovascular disease

25. Hyperinsulinemia & PCOS women with PCOS have a higher incidence of insulin resistance and hyperinsulinemia than age-matched controls 40% of women with PCOS have impaired glucose tolerance, and as many as 10% develop type 2 diabetes mellitus by the age of 40 hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, decreased sex hormone binding protien

26. DDx

27. Investigations Fasting insulin level or GTT (up to 38% of asymptomatic women with PCOS versus 8.5% in the general population had iGTT, 7.5% of those with frank diabetes) “according to ADA guidelines” Hormonal study : LH Level: Raised LH or LH:FSH ratio Estradiol Level Total and Free testosterone, androstendione(in the early morning, on days 4 through 10 of the menstrual cycle) DHEAS (marker for adrenal hyperandrogenism) Ultrasound pelvis

28. remember to exclude secondary causes of PCOS : Prolactin to rule out hyperprolactinemia TSH to rule out hypothyroidism 17-hydroxyprogesterone to rule out 21-hydroxylase deficiency (CAH). IGF-I to role out acromegaly Random serum cortisol to role out cushing syndrome Imaging For Tumors

31. Ultrasonographic appearance of a polycystic ovary in a 15-year-old with PCOS Ovary containing more than10 follicles that are approximately 3 to 8 mm in diameter

32. Managment Medical treatment of PCOS is tailored to the patient's goals. Broadly, these Goals may be considered under four categories: Obesity and insulin resistance Restoration of fertility Treatment of hirsutism or acne Restoration of regular menstruation

33. Compined OCP The first-line treatment for adolescents who suffer the menstrual and cutaneous symptoms of PCOS The progestin component inhibits endometrial proliferation, preventing hyperplasia (control menses). The estrogen component reduces excess androgen, which improves menstrual irregularity, dysfunctional uterine bleeding, hirsutism, and acne. As a general rule, OCPs should be continued until the patient is gynecologically mature (five years postmenarcheal)

34. Obesity and insulin resistance Diet & Exercise: since PCOS is associated with overweight or obesity, successful weight loss and Low carb Diet is probably the most effective method of restoring normal ovulation/menstruation Medication: Metformin(recommended by NIH if BMI<25) “increases the frequency of ovulation 50%” Thiazolidinediones

35. Infertility anovulation is a common cause for Infertility clomiphene citrate and FSH are the principal treatments used to help infertility metformin is not recommended for ovulation stimulation, as there was a large study comparing clomiphene with metformin, clomiphene alone was the most effective, 626 women were randomized to three groups: metformin alone, clomiphene alone, or both. The live-birth rates following 6 months of treatment were 7.2% (metformin), 22.5% (clomiphene), and 26.8% (both) Glucocorticoid therapy to suppress adrenal source of androgen

36. The most drastic increase in ovulation rate occurs with a combination of diet modification, weight loss, and treatment with metformin and clomiphene citrate If previous measures failed we go to : ovarian hyperstimulation with FSH + IVF ovarian drilling (puncture of 4-10 small follicles with electrocautery)

37. Hirsutism and acne The goal of is to decrease the effect of excess androgens by: Reducing their production : Cyproterone acetate (progestogen with anti-androgen effects) &Metformin(lowers testosterone 20%) Reducing free plasma androgen levels by increasing androgen binding to plasma-binding proteins (OCP) Blocking androgen action at the level of target organs (eg, hair follicle): Flutamide(Androgen receptor antagonist) &Spironolactone(antiandrogenic compound)

38. Menstrual irregularity & DUB contraceptive pills (often can be controlled with cyclic progestin alone) The purpose of regulating menstruation is essentially for the woman's convenience and preventing DUB If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required - most experts consider that if a menstrual bleed occurs at least every three months, then the endometrium is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer

39. Some OCP limitations OCP therapy may make weight loss more difficult to attain because they promote salt and water retention. In perimenarcheal girls with short stature who have open epiphyses, OCPs are contraindicated because OCPs contain growth-inhibitory amounts of estrogen. Risk of venous thromboembolism