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PCOS Polycystic Ovary Syndrome

PCOS Polycystic Ovary Syndrome. Objectives. Know the clinical definition of PCOS Know the typical physical and laboratory findings associated with PCOS Be familiar with the current management options. Definition. Polycystic ovary syndrome is a clinical diagnosis

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PCOS Polycystic Ovary Syndrome

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  1. PCOSPolycystic Ovary Syndrome

  2. Objectives • Know the clinical definition of PCOS • Know the typical physical and laboratory findings associated with PCOS • Be familiar with the current management options

  3. Definition • Polycystic ovary syndrome is a clinical diagnosis • 2 or more of the following features: • Chronic oligo-ovulation or anovulation • Androgen excess • Polycystic ovaries

  4. Epidemiology • Affects 5-10% of women of childbearing age • Most common cause of anovulatory infertility in developed countries • Prevalence of the metabolic syndrome is 2-3x higher among women with PCOS

  5. Theories to Etiology of PCOS • Genetic predisposition • Most likely although no gene isolated • Premature adrenarche (<8 y/o) • Heterozygosity for congenital adrenal hyperplasia (CAH) • Intrauterine Growth Retardation (IUGR)

  6. Pathophysiology • Majority of women with PCOS (regardless of weight), have insulin resistance • Association with: type 2 diabetes, dyslipidemia, and hypertension • Effects of hyperinsulinemia • Ovaries remain sensitive to insulin (maybe hypersensitive)  Androgen excess • Inhibits hepatic production of sex hormone binding globulin  increases circulating free testosterone • Impedes ovulation

  7. Nestler J. N Engl J Med 2008;358:47-54

  8. Cascade leading to excess androgens

  9. CYCLE STARTS Vicious Cycle of PCOS

  10. Clinical Findings • Anovulation  amenorrhea & infertility • Hirsuitism • Acne Vulgaris • Male pattern baldness/thinning • Obesity- android-type with waist-hip ratios • Cancer- endometrial

  11. Pregnancy PCO Hypothyroidism Ovarian tumor Pituitary tumor CAH Female Athlete Triad (hypothalamic amenorrhea) Turner’s syndrome Testicular Feminization Evaluation: Differential Dx MORE LIKELY LESS LIKELY

  12. Knowing all of this, what laboratory tests would you order for a patient you are suspecting of PCOS?

  13. B-HCG Thyroid LH/FSH Prolactin Free/total testosterone Fasting 17-OPH and cortisol Fasting glucose Fasting Insulin level Fasting Lipid profile Androstenedione DHEAS Karyotype Laboratory Tests to Consider in Evaluation Process RED - those tests most critical to diagnosis of PCOS GREEN – consider these tests as associated problems with PCOS

  14. Ultrasound Findings

  15. Problems associated with high levels of sex hormones: • Insulin resistance • Hyperinsulinemia • Diabetes • Cardiovascular disease

  16. Management: Non-medical • Weight control • Low carb diets • Exercise • reduce weight and CV risk factors • Increase insulin sensitivity

  17. Management: Medical • OCP’s: • suppress LH androgens • SHBG  free testosterone • adrenal production of androgen •  5alpha-reductase • Spironolactone • Cyclic progestins • GnRH agonists

  18. Management: Metformin • Reduces hyperinsulinemia • Decreases risk factors for CHD • Improved weight-loss • Normalization of circulating androgens • Resumption of normal ovulatory menses and therefore reversal of infertility

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