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 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 Complications infertility endometrial hyperplasia and cancer due to unopposed estrogen exposure associated with increased insulin resistance