Polycystic Ovarian Syndrome: Etiology, Diagnosis and Management
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Polycystic Ovarian Syndrome is a complex disease, with a constellation of etiology and symptoms. Much of the diagnosis is dependent on the laboratory tests of hormones. This presentation provides a concise and focused approach towards PCOS diagnosis and management.
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Polycystic Ovarian Syndrome: Etiology, Diagnosis and Management
- 1. Polycystic Ovarian Syndrome (PCOS) APARAJEYA SHANKER
- 2. Polycystic ovary syndrome is a clinical syndrome characterized by mild obesity, irregular menses or amenorrhea, and signs of androgen excess (eg, hirsutism, acne). 20-30% of patients have multiple cysts in the ovaries. Diagnosis is by pregnancy testing, hormone measurement, and imaging to exclude a virilizing tumor. Treatment is symptomatic. DEFINITION
- 3. IMPORTANT CONSIDERATIONS PCOS is a complex, heterogenous disorder, which is largely caused by a disturbance in the metabolic pathways and hyperandrogenism It is also an endocrine disorder with Insulin Resistance, Sub-fertility, hyperandrogenism PCOS is a cause of major concern as it is the most common endocrine disorder in women and is the leading cause of Anovulatory subfertility The presence of cysts in the ovary is not always required for a PCOS diagnosis (Rotterdam diagnostic Criteria will be discussed later) There is no known cause of the disease, although multiple theories exist on its etiology DEFINING PCOS COMPREHENSIVELY PCOS is a complex metabolic disorder that is characterized by chronic anovulation, increased androgen production and associations with metabolic derangements such as insulin resistance, hyperlipedemia and obesity. No exact cause is known for PCOS but evidence suggests that it is a disease caused by the complex interaction of genetic and environmental factors
- 4. Diagnostics There are two criteria that can be used for diagnosing PCOS, however, the consensus is on the Rotterdam criteria ROTTERDAM CRITERIA Two out of three factors required for diagnosis: Anovulation or oligo-ovulation/amenorrhea or oligomenorrhea Clinical or Biochemical Hyperandrogenism Ultrasound Evidence of multiple cysts 1. 2. 3. ANDROGEN EXCESS AND PCOS SOCIETY Evidence of hyperandrogenism and ovarian dysfunction
- 5. Exact etiology and pathogenesis is not known, however, LH hypersecretion is observed and believed to cause hyperandgrogenemia Oversecretion of LH leads to increased Thecal Cell activity in the ovaries. This can then lead to the secretion of DHEA and androgens. However, lower FSH in comparison to LH, does not allow the conversion of androgens to estrogens Lower estrogen causes anovulation These factors are combined with Insulin Resistance and lowered Sex Hormone Binding Globulins Further, this constellation causes the formation of Metabolic syndrome 1. 2. 3. 4. 5. ETIOLOGY OF PCOS
- 6. Elevated LH Comparatively lower FSH Elevated Testosterone Lowered SHBG Elevated Insulin Elevated Estrogen Lowered Progesterone Lowered TSH Biomolecules/hormones affected in PCOS BIOCHEMICAL CONSTELLATION ESTROGEN LEVELS MAY BE ELEVATED DUE TO INCREASED AROMATASE (E1) TESTOSTERONE LEVELS MAY BE ONLY SLIGHTLY ELEVATED Elevated Prolactin Elevated T4 Lowered HDL Elevated LDL
- 9. DIAGNOSTIC EVALUATION HISTORY Menstruation Adrenal enzyme deficiency Hirsutism Infertility Metabolic Syndrome Diabetes/Insulin Resistance FAMILIAL IRREGULARITIES OF PHYSICAL LABORATORY ANALYSIS IMAGING Insulin Resistance: Obesity and Acanthosis Nigricans, Metabolic Syndrome Hyperandrogenemia: Hirsutism, Acne, Alopecia (Exclude Virlization) Pregnancy Hormone levels Glucose Lipid Panel Transvaginal Ultrasound MRI for Adrenal Glands Diagnostic evaluation is largely meant to exclude Virilization, Diabetes, Cushing's Syndrome, Pituitary Tumours, Polycystic Ovaries etc. The differential Diagnosis of PCOS is vast.
- 10. Waist Circumference Triglycerides HDL Blood Pressure Fasting Glucose Hypertension Diabetes Obesity >88cm Insulin Resistance in Women LABORATORY ANALYSIS Three or more of the following: >150 mg/dL <50 mg/dL >130/85 >110 mg/dL Metabolic Syndrome
- 11. 5-20 ng/ml FSH Elevated. If above 600ng/dL, consider virilization Testosterone Lowered SHBG Elevated, indicative of Insulin resistance and registers as hyperinsulinemia Insulin Elevated Estrogen Lowered Progesterone To rule out hyperthyroidism TSH Elevated Prolactin Elevated T4 Lowered HDL Elevated LDL Test for Pregnancy hCG 5-20 ng/ml Hormonal Profile LABORATORY ANALYSIS LH LH:FSH ratio 2:1 (They might fall within normal range individually, but the ratio will be abnormal) To rule out congenital adrenal Hyperplasia 17-Hydroxyprogesterone Elevated DHEA