3. • Polycystic ovary syndrome (PCOS) is one of the most
common female endocrine disorders.
• PCOS is a complex, heterogeneous disorder of
uncertain aetiology, but strong evidence it can largely be
classified as a genetic disease
• PCOS produces symptoms in approximately 5% to 10% of
women of reproductive age (12–45 years old).
• It is thought to be one of the leading causes of female
subfertility and the most frequent endocrine problem in
women of reproductive age.
PCOS-What is it?
8. Anovulation
Resulting in irregular menstruation, amenorrhea, ovulation-
related infertility, and polycystic ovaries.
Excessive amounts or effects of androgenic hormones
Resulting in acne and hirsutism
Insulin resistance
Often associated with obesity, Type 2 diabetes, and high
cholesterol levels.
PCOS-Features
12. European Society of Human Reproduction and
Embryology (ESHRE) in Rotterdam indicated PCOS to
be present if any 2 out of 3 criteria are met
1.oligoovulation and/or anovulation
2.excess androgen activity
3.polycystic ovaries (by gynaecologic ultrasound)
In 2006, the Androgen Excess & PCOS Society
suggested a tightening of the diagnostic criteria to all of:
1.excess androgen activity
2.oligoovulation/anovulation and/or polycystic ovaries
3.other entities are excluded that would cause excess
androgen activity
PCOS-Diagnosis
13.
14. Other causes of irregular or absent menstruation and
hirsutism….
-hypothyroidism
-congenital adrenal hyperplasia (21-hydroxylase
deficiency)
-Cushing's syndrome
-hyperprolactinameia, androgen secreting
neoplasms, and other pituitary or adrenal
disorders
-PCOS has been reported in other insulin-resistant
situations such as acromegaly
PCOS-Differential Diagnosis
15.
16. The genetic component is autosomal dominant fashion with high genetic
penetrance but variable expressivity in females
The genetic variant(s) can be inherited from either the father or the mother, and
can be passed along to both sons (asymptomatic carriers or symptoms such as
early baldness and/or excessive hair) and daughters, who will show signs of PCOS
The allele appears to manifest itself via heightened androgen levels secreted
by ovarian follicle theca cells from women with the allele
The exact gene affected has not yet been identified
The clinical severity of PCOS symptoms determined by factors such as obesity.
PCOS aetiology
17. Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of
male hormones (androgens), particularly testosterone, by either one or a combination of the
following (almost certainly combined with genetic susceptibility)
the release of excessive LH by the anterior pituitary gland
through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries
are sensitive to this stimulus
Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased
free androgens
‘Cysts" are actually immature follicles, not cysts
The follicles have developed from primordial follicles, but the development has stopped
("arrested") at an early antral stage due to the disturbed ovarian function.The follicles may be
oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.
Women with PCOS have higher GnRH, which in turn results in an increase in LH/FSH ratio in
women with PCOS.
A majority of patients with PCOS have insulin resistance and/or are obese.
Hyperinsulinemia increases GnRH pulse frequency, LH over FSH
dominance, increased ovarian androgen production, decreased
follicular maturation, and decreased SHBG binding; all these steps
contribute to the development of PCOS.
PCOS Pathogenesis
18. In many cases PCOS is characterised by a complex positive feedback loop of insulin
resistance and hyperandrogenism.
In most cases it can not be determined which (if any) of those two should be regarded
causative.
Adipose tissue possesses aromatase, an enzyme that converts androstenedione to
estrone and testosterone to oestradiol.The excess of adipose tissue in obese patients
creates the paradox of having both excess androgens (which are responsible for
hirsutism and virilizattion) and oestrogens (which inhibits FSH via negative feedback).
PCOS Pathogenesis ctd
19. Medical treatment of PCOS is tailored to the patient's goals. Broadly,
these may be considered under four categories:
1. Lowering of insulin levels
2. Restoration of fertility
3. Treatment of hirsutism or acne
4. Restoration of regular menstruation, and prevention
of endometrial hyperplasia and endometrial cancer
PCOS-Management
20.
21. Women with PCOS are at risk for the following:
-Endometrial hyperplasia and endometrial cancer
-Insulin resistance/Type II diabetes
-High blood pressure, particularly if obese and/or during pregnancy
-Depression
-Dyslipidemia
-Cardiovascular disease
-Weight gain
-Miscarriage
-Sleep apnoea
-Non-alcoholic fatty liver disease
-Acanthosis nigricans (patches of darkened skin under the arms, in the groin
area, on the back of the neck)
-Autoimmune thyroiditis
PCOS-Prognosis
22. • Presumed to be genetic aetiology
• Complicated pathogenesis, due to increased
action of oestrogen
• Common
• Serious complications – fertility issues
• Easy spot signs, hirsutism, obesity etc
• Treatment is available
• Failure to treat increases risk of many other
diseases
PCOS -Summary
24. • Condition in which the endometrium is
found outside the uterine cavity
• Most commonly found in the Pouch of
Douglas, umbilicus and in scars after
gynae operations
• Endometriosis within the myometrium is
called adenomysosis
Endometriosis
25.
26. • Retrograde menstruation leading to
implantation
• Implantation of fragments at
operation
• Change of peritoneal mesothelial
cells to endometrial cells
Endometriosis-Aetiology
27. Common in Europe
Uncommon in negroes
COMMON IN NULLIPAROUS WOMEN
Pelvic pain
Dysmenorrhea
Menorrhagia
Frequent periods
Dysparenuia
Infertility
Pelvic pressure symptoms
Uterine retroversion
Thickening of the utero-sacral ligaments
Nodules of the Pouch of Douglas
Ovarian enlargements and cysts
Endometriosis- Features
30. • Endometrium where it shouldn’t be
• Endometrioma is large enough to be
classified a tumour and is called
chocolate cyst
• Oestrogen dependent
• No pathognomonic symptoms but pain,
mass and infertility common symptoms
• Treatment- Laser, Diathermy, Excision
Endometriosis-Summary
39. • Acute or Chronic helps to define
aetiology and enable bespoke and
suitable management
• Any Chronic cause can present acutely but
unlikely vice versa
Pelvic pain - Summary
41. History
-21 year old female referred to dermatologist complaining
of facial hair growth. Her skin has become more greasy
lately.
-Menarche was 13, her period has been erratic with
intermentstrual interval ranging 3 days to 3 months.
-She lives alone, smoke 20 cigarettes a day and drinks
about 20 units a week.
CASE
42. O/E
BMI 31
Greasy facial skin
Otherwise normal
FSH 1U/l LOW
LH 32U/l HI
Oestradiol 284nmol/24hr HI
Testosterone 8.2nmol/l HI
44. DDx of hirsutism
1.Constitutional
2.Drugs – Cyclosporin, Minoxidil
3. Cushings syndrome
4.CAH
5.Androgen secreting tumours
6. Hypothyroidism
Which two of these are the rarest causes?
