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Updated: Jan 7 2023

Polycystic Ovarian Syndrome

  • 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.
  • 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
  • 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
  • Ovarian ultrasonography
    • indications
      • can be performed when pelvic examination is inadequate
    • findings
      • may show polycystic ovaries affecting one or both ovaries
  • Labs
    • total and free testosterone level
    • LH/FSH > 3
  • Cushing syndrome
  • Non-classical congenital adrenal hyperplasia
  • Androgen-secreting tumor
  • Pregnancy
  • Premature ovarian failure
  • Thyroid disease
    • hyper- or hypothyroidism
  • Prolactinoma
  • 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
    • letrozole
      • indications 
        • first-line treatment for PCOS-caused infertility
    • clomiphene citrate
      • indications
        • alternate treatment for infertility caused by PCOS (previously first-line but now letrozole with better efficacy data)
        • 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
    • infertility
    • endometrial hyperplasia and cancer due to unopposed estrogen exposure  
    • associated with increased insulin resistance
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