Updated: 12/11/2019

Polycystic Ovarian Syndrome

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Snapshot
  • A 25-year-old woman presents with excessive hair growth and abnormal menses. She reports shaving mulitple times to remove hair from her chin and chest, states that her menses has been irregular, and is currently sexually active and only uses condoms as a form of contraception. She is not on any medications. The patient is 5' 1" (155 cm) and weighs 165 lbs (75 kg). On physical examination, there is hair in the periareolar and linea alba region. There is also acanthosis nigricans in the posterior neck.
Introduction
  • Clinical definition
    • an acquired endocrinopathy characterized by
      • ovarian dysfunction
        • can lead to primary or secondary amenorrhea and oligomenorrhea which
          • prevents formation of the corpus luteum, impairing progesterone synthesis which leads to
            • unapposed estrogen proliferative effect on the endometrium that results in
              • bleeding
              • increased risk of endometrial hyperplasia and cancer 
      • hyperandrogenism
        • may present as acne and hirsutism
      • polycystic ovaries
  • Epidemiology
    • incidence
      • ~7% of reproductive-aged women
    • demographics
      • females only
    • risk factors
      • family history
      • obesity
  • Pathophysiology
    • mechanism is unclear
      • peripheral insulin resistance leads to hyperinsulinemia
      • ovarian stimulation leading to excess androgen production
  • Associated conditions
    • infertility
      • the most common cause of infertility in woman
    • menstrual dysfunction
    • hyperandrogenism
    • obesity
    • insulin resistance 
  • Prognosis
    • natural history of disease
      • patients may present for hirsutism, irregularities in their menses, obesity, and acanthosis nigricans
    • prognostic variable
      • favorable
        • weight loss
Presentation
  • Symptoms
    • menstrual dysfunction
      • e.g., dysfunctional uterine bleeding and amenorrhea
    • infertility
    • hirsutism
    • acne
  • Physical exam
    • obesity
    • hirsutism
    • acne
    • acanthosis nigricans  
      • a sign of insulin resistance
    • bilateral enlarged ovaries on pelvic exam
Imaging
  • Ovarian ultrasonography
    • indications
      • can be performed when pelvic examination is inadequate
    • findings
      • may show polycystic ovaries affecting one or both ovaries
Studies
  • Labs
    • total and free testosterone level
    • LH/FSH > 3
Differential
  • Cushing syndrome
  • Non-classical congenital adrenal hyperplasia
  • Androgen-secreting tumor
  • Pregnancy
  • Premature ovarian failure
  • Thyroid disease
    • hyper- or hypothyroidism
  • Prolactinoma
Treatment
  • Lifestyle
    • weight loss  
      • indications
        • for obese patients, weight loss is the first-line of treatment
        • for obese patients pursuing pregnancy
  • Pharmcologic
    • hormonal contraceptives    
      • indications
        • first-line of treatment for anovulation
        • first-line of treatment for hirsutism/acne
    • metformin
      • indications
        • first-line of treatment for the insulin resistance associated with PCOS
          • also known to improve ovulation and assist in reducing androgen levels to improve regular menstrual cycles
    • clomiphene citrate
      • indications
        • first-line of treatment for infertility caused by PCOS
        • can cause heterotopic pregnancy 
  • Operative
    • bariatric surgery
      • indications
        • for treatment of obesity
    • ovarian-drilling
      • indications
        • can be considered in patients who are refractory to clomiphene citrate
Complications
  • Complications
    • infertility
    • endometrial hyperplasia and cancer due to unopposed estrogen exposure  
    • associated with increased insulin resistance
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.13.255) A 27-year-old woman presents to her primary care physician for difficulties getting pregnant. She and her husband have been having unprotected intercourse once per day without success for the past year. She reports irregular menses. She is otherwise healthy and is not taking any medications. Her temperature is 98.0°F (36.7°C), blood pressure is 144/88 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical examination is notable for acne and the finding in Figure A. The patient has a notable abdominal pannus without any rashes noted. The patient is subsequently worked up with a TSH, prolactin level, and hysterosalpingogram, all of which are normal. She is instructed to lose weight and given a prescription for metformin. The patient returns 3 months later, and her urine hCG is negative. The treating physician is considering prescribing a second line medication. What potential side effect must the physician warn the patient about? Review Topic | Tested Concept

QID: 106211
FIGURES:
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Facial hair

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Heterotopic pregnancy

10%

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Hypoglycemia

80%

(8/10)

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Increased insulin sensitivity

10%

(1/10)

5

Weight gain

0%

(0/10)

L 3 E

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