POLYCYSTIC OVARY SYNDROME

PCOS is characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism & polycystic ovaries.

Diagnostic clinical feature includes menstrual dysfunction, acne, obesity, infertility, hirsutism, metabolic syndrome & associated with Hypertension, Endometrial hyperplasia/carcinoma, depression, Fatty liver disease, Mood disturbances and increased risk of diabetes mellitus, & cardiovascular disease.

ETIOLOGY AND PATHOPHYSIOLOGY:

primary role for insulin resistance with hyperinsulinemia.

Increased GnRH pulsations from hypothalamus leads to increased LH production & limited FSH production.

Hyperandrogenism: Ovaries are main source of androgens excess (75% of circulating testosterone originates in ovary).

Polycystic ovaries have thickened thecal layers & overexpressed LH receptors, that causes excess androgen secretion.

Ovarian follicles: Abnormal androgen signaling which account for abnormal folliculo genesis & leads to polycystic ovaries.

Obesity results to compensatory hyperinsulinemia: PCOS women have insulin resistance similar in type 2 DM.

Elevated insulin decrease sex hormone binding globulin, & increasing bioavailability of testosterone.

Insulin acts directly on ovaries, adrenal glands, and hypothalamus to enhance production of androgen.

Insulin resistance causes elevation of level of insulin & usually associated metabolic syndrome or DM.

POLYCYSTIC OVARY SYNDROME (PCOS, SteinLeventhal Syndrome):

A diagnosis of PCOS must have three criteria-

(1) androgen excess & clinical hyperandrogenism or increased total or free testosterone;

(2) ovarian dysfunction & oligoanovulation or polycystic ovarian morphology;

(3) absence of other causes of testosterone excess or anovulation like pregnancy, thyroid dysfunction, neoplastic testosterone secretion, 21-hydroxylase deficiency, Cushing syndrome, or hyperprolactinemia.

Symptoms & Signs:

PCOS presents as a menstrual disorder- amenorrhea to menorrhagia & infertility.

Peripheral androgen excess- hirsutism and acne

Signs of insulin resistance & hyperinsulinemia, increased risk of metabolic syndrome & early-onset type 2 diabetes mellitus.

Pregnant patients are at increased risk of perinatal complications, like gestational diabetes and preeclampsia.

Increased risk for endometrial cancer because of unopposed secretion of estrogen.

Investigations:

PCOS- LH/FSH level ≥2.5 to 3.0 in about 50% of PCOS women. USG shows polycystic ovaries.

Transvaginal USG: one or both ovaries with ≥12 follicles measuring 2 to 9 mm or increased in ovarian volume to 10 cm3.

Do serum FSH, LH, hemoglobin A1C, fasting glucose, lipid profile, fasting insulin, C-peptide, BMI.

Determination of anovulation- a midluteal phase progesterone level (>3 ng/mL if woman has ovulated).

Anovulation due to

(1) premature ovarian failure (low estradiol, high FSH)- do estradiol, FSH.

(2) functional hypothalamic amenorrhea, that is associated with rapid weight loss or extreme physical exertion (low to normal LH & FSH for age)- do LH, FSH.

(3) discontinuation of hormonal contraceptives (return of ovulation occurs within 90 days).

(4) pituitary adenoma with prolactin elevation (galactorrhea may present)- do prolactin.

(5) hyperthyroidism or hypothyroidism- do thyroid function test.

(6) pregnancy- do human chorionic gonadotropin (hCG).

Hirsutism- do free testosterone determination (total testosterone minus SHBG) and a DHEAS.

Clinical evidence of androgen excess- do total testosterone, free (bioavailable) testosterone,

& 17-hydroxyprogesterone.

Cushing syndrome- 24-hour urinary free cortisol or a low-dose dexamethasone suppression test.

Congenital adrenal hyperplasia & androgen secreting adrenal tumors- high circulating androgen levels & polycystic ovaries with anovulation.

Endometrial biopsy to rule out endometrial hyperplasia and/or carcinoma, if needed.

Treatment:

Lifestyle modification including changes to diet and physical activity.

Obese PCOS- weight reduction and exercise, effective in reversing the metabolic effects & in inducing ovulation.

If not responding may be added metformin, that is beneficial in metabolic or glucose abnormality, & may useful in improving menstrual function.

Initial dose of metformin is 500 mg daily for 1 week, increase 500 mg/week, 2,000 mg/day divided doses, taken with food.

Contraceptive counseling to prevent unplanned pregnancy if return of ovulatory cycles occurs.

Women seeking pregnancy & remain anovulatory- clomiphene used for ovarian stimulation, is first-line therapy for infertility.

If fails, treatment with gonadotropins, at low dose to reduce risk of ovarian hyperstimulation syndrome.

Letrozole may first-line for ovulation induction.

Not desire pregnancy or contraception- medroxyprogesterone acetate 10 mg/day orally

for the first 10 days in every 1–3 months, for regular shedding of endometrium & to avoid endometrial hyperplasia.

Contraception desired- combination hormonal contraceptives (pill, ring, or patch), useful in controlling hirsutism, continued for 6–12 months for results. Low-dose OCPs (30 to 35 μg)

Levonorgestrel-releasing IUD to minimize uterine bleeding & protect from endometrial hyperplasia, not useful to control hirsutism.

Acne treatment: OCPs with low-androgenicity progestins (like norethindrone, desogestrel, norgestimate) & Spironolactone useful.

Hirsutism- (details in hirsutism video)

Spironolactone, 25-200 mg daily devided doses.

Flutamide, 125–250 mg orally daily.

Finasteride, 2.5- 7.5 mg orally daily.

These are teratogenic, so use contraception.

Topical Eflornithine hydrochloride 13.9% cream BID, depilatory creams, electrolysis, and laser therapy, waxing.

Weight loss, exercise, treatment of metabolic problems useful in preventing cardiovascular events.

Regular monitoring of weight, lipid profiles & glucose.

Adolescent PCOS- option hormonal contraceptives & metformin.

Advice From- DR RAKESH UKEY MBBS, MD MEDICINE.:-

Please consult in clinic, then start medicine according to diagnosis.

Clinic No. +917744491139.

We Want You To Be Healthy Today. RMC Walk-In-Clinic, We Update Daily Our Clinic Cases For General Information Only.

Owner Of Highly Reputable Rakesh Multispeciality Clinic.

International Associate Member Of American College Of Cardiology (ACC), Member Of Indian Medical Association (IMA).

Certified from Royal College of physician of the United Kingdom (UK), Journal Of American College Of Cardiology (ACC), ETC.

Is One Of The Leading Physician, Best Doctor In RAJNANDGAON CHHATTISGARH For Difficult Diagnosis And Treatment In Neurology, Cardiology, Gastro+ Hepatology, Respiratory Medicine, Rheumatology, Hematology, Nephrology, Endocrinology, Infectious, Geriatric, Diseases, Women’s & Men’s Health Issue, Etc.

Online Advice-

For Appointment. Pay Fee In Payment Link Given Below.

https://www.instamojo.com/@drrakeshukey/l55370e300fae49969f3b8739eac81429/

Inform Or Call For Any Help On Manager Mobile No. +919145035204 Or Clinic +917744491139. We Will Call You Within 2 Hour.

For More Details Visit In-

https://www.facebook.com/DrRakeshUkeyMD

https://www.instagram.com/dr_rakesh_ukey_md/

https://twitter.com/ukey_rakesh https://www.linkedin.com/in/dr-rakesh-ukey-82051635/