Definition, Epidemiology, Pathophysiology, Clinical Features, Investigation and Treatment of PCOS

1. POLYCYSTIC OVARIAN
SYNDROME
By
Dr. Ayodele Nosrullah
Department of Obstetrics and Gynaecology,
Federal Medical Center, Birnin Kebbi
27/02/2019
1

2. OUTLINE
• Introduction
• Aetiology
• Pathophysiology
• Clinical features
• Differential diagnosis
• Investigations
• Treatment
• Complications
• Summary
• Conclusion
• References 2

3. INTRODUCTION
• Polycystic ovary syndrome (PCOS) is a
heterogeneous disorder that is defined by
a combination of signs and symptoms of
androgen excess and ovarian dysfunction
with the clinical manifestations of
oligomenorrhoea, subfertility, hirsutism
and acne 1,2
3

4. INTRODUCTION
• Other names 2
• Polycystic ovary disease,
• Functional ovarian hyperandrogenism,
• Ovarian hyperthecosis,
• Sclerocystic ovary syndrome
• Stein-Leventhal syndrome
• First described in 1935 by the American
gynaecologists Irving F Stein and Michael
L Leventhal 2
4

5. INTRODUCTION
• It is the most common endocrine
disorder of women of reproductive age
group 3
• Prevalence varies among races and
ethnicities
• USA – 4-12% 3,4,5
• European studies – 6.5-8% 5
• Ilorin (Northern Nigeria) – 12.2% 4
• Benin (Southern Nigeria) – 27.6% 8
5

6. INTRODUCTION
• Affects premenopausal women, and the
age of onset is most often perimenarchal5
• Associated with clinical, social and
psychological problems.
• Management aims to lower body weight
and insulin levels, restore fertility, restore
regular menstruation, treat hirsutism or
acne, and prevent complications.
6

7. AETIOLOGY
• Underlying cause is unknown
• Genetic basis being suspected
• Autosomal dominant – first degree males
symptoms
• Twin studies
• Dysregulation of CYP 11a gene
• Upregulation of other enzymes in androgen
synthesis pathway
• Insulin receptor gene on chromosome 19p13.2
• Decreased sex hormone binding globulin
7

8. AETIOLOGY
• Others (predisposing factors) 2
• Family history of PCOS
• High maternal androgen
• Onset of type 1 diabetes mellitus before
menarche
• Insulin resistance
• Obesity
• Drugs e.g. valproate
8

9. PHYSIOLOGY OF MENSTRUATION
9HYPOTHALAMO-OVARIAN PITUITARY SYSTEM

10. 10
estriol
16α-hydroxylase
STEROID HORMONE SYNTHESIS
Desmolase
PHYSIOLOGY OF MENSTRUATION

11. MENSTRUAL CYCLE 11
PHYSIOLOGY OF MENSTRUATION

12. PATHOPHYSIOLOGY
12

13. CLINICAL FEATURES
• Features of menstrual dysfunction
• Features of hyperandrogenism
• Hirsutism /Acne /Androgenic alopecia
• Other endocrine dysfunction
• Insulin resistance/diabetes mellitus
• Obesity
• Acanthosis nigricans
• Infertility/miscarriages
• Obstructive sleep apnoea
• Metabolic syndrome
• Endometrial neoplasia
13

14. 14
HIRSUTISM
ACNE

15. DIAGNOSTIC CRITERIA
• Controversies on what constitute PCOS 3
• It is a diagnosis of exclusion1,2,3
• NIH, 1990: includes both of
• Oligo-ovulation
• Hyperandrogenism and/or hyperandrogenaemia
(with exclusion of related disorders)
15

16. DIAGNOSTIC CRITERIA
• ESHRE/ASRM (Rotterdam criteria)
2003: to include 2 out of the following 3
• Oligo- or anovulation
• Clinical and/or biochemical signs of
hyperandrogenism
• Polycystic ovaries
• RCOG recommends the use of Rotterdam
criteria 1
16

17. DIAGNOSTIC CRITERIA
Other available criteria:
• AE-PCOS, 2009
• Hyperandrogenism: hirsutism and/or
hyperandrogenaemia, and
• Ovarian dysfunction: oligo-anovulation and/or
polycystic ovaries, and
• Exclusion of the other androgen-excess or related
disorders
17

18. DIFFERENTIAL DIAGNOSIS
• Hyperthyroidism
• Hypothyroidism
• Hyperprolactinaemia
• Hypogonadotropic hypogonadism
• Primary ovarian failure
• Acromegaly
• Late onset CAH
• Androgen secreting ovarian tumour
• Androgen secreting adrenal tumour
• Cushing syndrome
• Exogenous androgen use 18

19. INVESTIGATIONS
Biochemical tests
• FSH, LH
• Testosterone – total and free, FAI
• Thyroid function tests
• Serum prolactin
• Blood sugar test (2hr GTT)
• Fasting insulin level
• Fasting lipid profile
• DHEAS
• 17α hydroxyprogesterone
• Cortisol 19

20. INVESTIGATIONS
Radiological tests
• Ultrasound scan
• CT scan
• MRI scan
Histology
• Endometrial biopsy
20

21. • No universal treatment for PCOS is
available 6
• Treatment is individualized, based on:
• Woman’s goal
• Severity of symptoms
• Modalities include:
• Conservative
• Medical
• Surgical
21
TREATMENT

22. TREATMENT
Conservative
• Fairly regular cycle intervals (8 to 12
menses per year)
• Mild hyperandrogenism
• Encourage weight loss
• Diet modification
• Exercise
• Periodic screening for dyslipidemia and
diabetes mellitus
22

23. TREATMENT
Medical management aims to 2
• Lower insulin levels
• Restore regular menstruation
• Restore fertility
• Treat hirsutism or acne,
• Prevent endometrial hyperplasia and
endometrial cancer.
23

24. MEDICAL TREATMENT
Restoration of ovulation/menstruation
• Combined Oral Contraceptive Pills
• Suppress gonadotropin release
• Reduce androgen levels
• Induce regular menstrual cycles
• Cyclic progestogens
• When COCP is contraindicated (e.g. MPA)
• Intrauterine progestogen device (IUS or
implants) 2
• Insulin sensitizing agents 24

25. MEDICAL TREATMENT
Insulin resistance / hyperinsulinaemia
• Metformin (NICE, 2004) 2
• improves peripheral insulin sensitivity by reducing
hepatic glucose production
• increases target tissue sensitivity to insulin
• decreases androgen levels
• helps spontaneous ovulation
• Thiazolidinedione 3
• improves entry of glucose into muscle and fat
• suppresses hepatic gluconeogenesis.
25

26. MEDICAL TREATMENT
Treatment of infertility
• Clomiphene citrate
• Tamoxifen
• Clomiphene+Metformin
• Gonadotropin alone or with hCG
• Assisted Reproductive Technology
26

27. MEDICAL TREATMENT
Treatment of hirsutism
• COCP
• Lowers androgen level
• Oestrogen component increases SHBG
• Eflornithine hydrochloride
• GnRH agonists
• Antiandrogens (e.g. spironolactone,
cyprotene acetate, flutamide)
• 5α reductase inhibitor (e.g. finasteride)
• Hair removal – depilation, epilation
27

28. MEDICAL TREATMENT
Treatment of acne
• COCP
• Topical Retinoids
• Topical Benzoyl Peroxide
• Topical and Systemic Antibiotics
• Isotretinoin
28

29. MEDICAL TREATMENT
Alternative medicine 2
• Acupuncture
• Helps menstrual regulation
• Decreases body weight
• Reduces headache
• Improves mood
• Myo-inositol
• Promotes proper insulin utilization
• Balances ovarian hormone functions
• Regularises menstrual cycle
• Improves fertility
29

30. SURGICAL TREATMENT
• Ovarian wedge resection (rarely done)
• Oophorectomy (rarely done)
• When fertility is not desired and symptoms are
severe
• Laparoscopic ovarian drilling (laser,
electrocautery, multiple biopsy)
• For clomiphene resistants
• Mechanism unclear
• May be due to destruction of androgen producing
stroma 30

31. COMPLICATIONS
31
Short term Long term
Obesity Diabetes mellitus
Infertility Endometrial cancer
Irregular menses Hypertension
Abnormal lipid levels Cardiovascular diseases
Hirsutism Depression
Acne Sleep apnoea
Glucose intolerance Reduces health-related
quality of life
Acanthosis nigricans

32. SUMMARY
• PCOS is a clinical disorder associated
with hormonal and menstrual
abnormalities
• It may be associated with short and long
term complications
• Diagnosis involves clinical, laboratory
and radiological methods
• Treatment depends on the need of the
patient and severity of symptoms
• Treatment can be conservative, medical
or surgical 32

33. CONCLUSION
Polycystic ovarian syndrome is one of the
most important endocrine disorders that
affects females in the reproductive age and
may lead to serious complications.
Further studies are needed to determine the
exact aetiology of PCOS, methods of
prevention and proper management.
33

34. REFERENCES
1. Royal College of Obstetricians & Gynaecologists. Long-term
consequences of polycystic ovary syndrome: green-top
guideline No 33. Royal College of Obstetricians and
Gynaecologists. 2014.
2. Kabel AM. Polycystic ovarian syndrome: insights into
pathogenesis, diagnosis, prognosis, pharmacological and non-
pharmacological treatment. J Pharma Reports. 2016 Jan
1;1(103):2.
3. Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM,
Schaffer JI. Williams gynecology. McGraw-Hill
Interamericana; 2017.
4. Omokanye L O, Ibiwoye-Jaiyeola O A, Olatinwo A, Abdul I F,
Durowade K A, Biliaminu S A. Polycystic ovarian syndrome:
Analysis of management outcomes among infertile women at
a public health institution in nigeria. Niger J Gen Pract
2015;13:44-8
34

35. REFERENCES
6. https://emedicine.medscape.com/article/256806-overview.
Accessed online 20/02/2019
7. Escobar-Morreale HF. Polycystic ovary syndrome: definition,
aetiology, diagnosis and treatment. Nature Reviews
Endocrinology. 2018 Mar 23.
8. Akpata CB, Uadia PO, Okonofua FE. Prevalence of Polycystic
Ovary Syndrome in Nigerian Women with Infertility: A
Prospective Study of the Three Assessment Criteria. Open
Journal of Obstetrics and Gynecology. 2018 Sep
29;8(12):1109.
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36. THANK YOU
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