Polycystic ovarian syndrome (PCOS) is a condition of unexplained hyperandrogenic chronic anovulation that most likely represents a heterogenous disorder. About 10% of women in the reproductive age group suffer from this disorder.

1. Polycystic ovarian syndrome
Amila Weerasinghe
21st Batch
Faculty of Medical Sciences
University of Sri Jayewardenepura
Sri Lanka
05/04/2016

2. Objectives
1. Introduction
2. Aetiology
3. Clinical features
4. Diagnosis
5. Management
6. Outcomes

3. 1. Introduction
• A syndrome of ovarian dysfunction
with
cardinal features of hyperandrogenism
polycystic ovary morphology
• Often complicated by chronic anovulatory infertility
• Clinical manifestations include oligomenorrhoea,
hirsutism and acne

4. • Many women are obese and have a higher
prevalence of
 impaired glucose tolerance,
 type 2 diabetes and
 sleep apnoea
• They exhibit an adverse cardiovascular risk
profile.

5. • Cardiometabolic syndrome as suggested by a
higher reported incidence of ,
hypertension
dyslipidaemia
 visceral obesity
insulin resistance
 hyperinsulinaemia

6. • Prevalence - 5 – 10 % of women of
reproductive age
• The commonest cause for anovulation (80%)
• USS evidence of polycystic ovaries in 20-30 %
of women
• The most common endocrine disorder in
women

8. High risk groups
• Women with oligo ovulatory infertility
• Obesity and/or insulin resistance
• Type 1 , type 2 or gestational diabetes mellitus
• A history of premature adrenarche
• First-degree relatives with PCOS
• Women using antiepileptic drugs (valproate)

9. 2. Aetiology
• Not fully known
• No gene or specific environmental substance
has been identified.
• Genetic studies showed a link between PCOS and
metabolic disturbances such as disordered
insulin metabolism.
• Hence it may be a manifestation of a complex
genetic disorder.

10. • Selective insulin resistance may be central to the
aetiology of PCOS.
• Compensatory hyperinsulinaemia
• Decreased levels of serum hormone binding
globulin (SHBG)
• Trophic stimulus to androgen production in the
adrenals and ovaries
• Direct effect on the hypothalamus causing
abnormally stimulated appetite and increased
gonadotropin secretion

11. • Hypersecretion of LH
Stimulation of androgen secretion from
ovarian thecal cells
• Elevated LH : FSH ratio

12. 3.Clinical features
• Oligomenorrhoea / amenorrhoea - 75%
• Hirsutism
• Subfertility 75%
• Obesity 40%
• Recurrent miscarriage 50 – 60%
• Acanthosis nigricans
• Asymptomatic

17. 4.Diagnosis
2 out of 3 features of Rotterdam criteria
• Amenorrhoea/oligomenorrhoea (cycle >42 days)
• Clinical or biochemical hyperandrogenism
( acne, hirsutism,alopecia )
• Polycystic ovaries on ultrasound
( 8 or more subcapsular follicular cysts <10mm in
diameter and increased ovarian stroma)

18. USS
• Bilateral enlargement of the ovaries > 8.0 cm.
Increased ovarian volume ( >10ml ).
• Thickened tunica albugenea
• Multiple small cysts (12 foliclles or lesser) of
0.2-0.9 cms in each ovary
• Absence of dominant follicle
• Thickened stroma (hyperthecosis)
• Resting or follicular endometrium

21. Laboratory investigations:
• Demonstration of biochemical hyperandrogenaemia.
– Total testosterone (>200ng/dL)/ Free testosterone
> 2.2pg/mL.
• S. Estradiol and FSH estimations.
– Exclude hypogonadotropic hypogonadism
( E2, FSH).
– Exclude premature ovarian failure
( E2, FSH).

22. • S. Dehydroepiandrosterone sulfate.
– Not of value if S. Testosterone is normal
– Values > 430μg/dL significant. It is indicative
of adrenal source of androgens.
– Levels > 700 μg/mL suggestive of androgen
producing adrenal tumour.
• 24 hours urinary cortisol
– Cortisil < 50 μg/24 hours
– Exclude Cushing’s syndrome if patient is
hypertensive.

23. Exclusion of other causes of
hyperandrogenism.
– Estimation of TSH to exclude thyroid dysfunction
– Estimation of serum prolactin to exclude
hyperprolactinemia
– Estimation of 17α hydroxyprogesterone.
Non classical congenital adrenal hyperplasia caused by
21-hydoxylase deficiency.

24. – Consider screening for Cushing’s syndrome,
and
– Rare conditions like acromegaly.
– Evaluation for metabolic syndrome X.

25. 5. Management
Treatment goals of polycystic ovary syndrome:
– Prevent endometrial hyperplasia, atypia/ cancer
– Restore normal ovulation / fertility
– Restore normal menstruation
– Correct hirsutism

26. Aspects of management
1. Lifestyle modification
2. Improving menstrual regularity
3. Controlling symptoms of hyperandrogenism
4. Subfertility
5. Insulin sensitizers
6. Psychological issues

27. 1.Lifestyle modification
• Weight reduction through exercise and diet – the
most important step in managing overweight
women.
• Even a modest weight loss (5%) can improve
symptoms.
• Effective in restoring ovulatory cycles and
achieving pregnancy.

31. 2. Improving menstrual regularity
• Weight loss
• Combine oral contraceptive pills (COCP)
 inhibits LH
 Reduces circulating androgens
 increases circulating SHBG
Low dose combination pill containing low dose
of synthetic estrogen in combination with a low-
androgenic progestin

32. • Metformin
Benificial in patients with hyperinsulinaemia
and CVS risk factors.
Improves peripheral insulin sensitivity;
 improve ovulation rates
 improve glucose tolerance
 increased SHBG leading to reduced
bioavailability of androgens

33. 3. Controlling symptoms of
hyperandrogenism
• Mainly hirsutism
1st line treatment
Weight reduction
COCP
Medroxyprogesterone acetate

34. 2nd line treatment
Spironolactone
Cyproterone acetate
Finasteride
Flutamide
Eflornithine hydrochloride
GnRH agonists
Last resort
Ketoconazole

35. Cosmetic approaches
Permenent
Laser
Electrolysis
Non-permanent
Local chemical depilatories
Bleaching
Waxing
Tweezing
Mechanical epilators

36. 4. Subfertility
• Weight loss
• Ovulation induction with antioestrogens or
gonadotrophins
Clomiphene citrate
Is a selective estrogen receptor modulator
1st line treatment in women with PCOS and
anovulatory infertility
Ovulation rate 70-80 %
Pregnancy rate 30-40 % over 6 cycles

37. • Laparoscopic ovarian diathermy
Effective in patients who are resistant to
clomiphine.

38. • In vitro fertilization ( IVF )
when ovulation can’t be achieved; or doesn’t
succeed in pregnancy.

40. 5. Insulin sensitizers
Metformin
• Metformin combined with clomiphene citrate
increases ovulation and pregnancy rates.
• No significant increase in birth rate.
• No significant improvement in acne or
hirsutism.
• Lowers androgen levels.

41. 6. Psychological issues
• Symptoms can be distressing and resulting
lower self esteem.
• Holistic approach

42. Definite / common consequences of
PCOS
• Insulin resistance: Type-II diabetes
• Endometrial hyperplasia / atypia
• Gestational diabetes
• Sleep apnoea

43. Possible consequences of PCOS
• Hypertension
• Coronary heart disease
• Dyslipidemia
• ? Risk of ovarian cancer
• ? Risk of abortion

44. Summary