PCOS
Page 1: Title and Authors
Polycystic Ovary Syndrome (PCOS)
Author: Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE
Fields: Obstetrics and Gynecology, Reproductive Endocrinology and Infertility
Page 2: Additional Resources
Gynecology schedule for 2018-2019
Lecture decks available for download: Doc Ina's lectures for Obstetrics and Gynecology topics.
Page 3: References
Main Reference
Comprehensive Gynecology, 8th Edition, 2021Lobo RA, Gershenson DM, Lentz GM, Valea FA, editorsChapter 39, Polycystic Ovary Syndrome (pp. 824-836)
Yau TT, Ng NY, Cheung LP, Ma RC."Polycystic ovary syndrome: a common reproductive syndrome with long-term metabolic consequences."Hong Kong Med J. 2017 Dec; 23(6):622-634.doi: 10.12809/hkmj176308. Epub 2017 Nov 24.
Page 4: Outline of PCOS Presentation
Main Topics
Diagnosis
Insulin Resistance
Hypertension
Pathophysiology
Consequences
Treatment
Page 5: Overview of PCOS
Definition: Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in reproductive-age women.
First described in 1935 by Stein and Leventhal as a syndrome involving amenorrhea, hirsutism, and obesity associated with enlarged polycystic ovaries.
Prevalence: Affects 15% to 20% of reproductive-age women, varying by ethnicity.
Page 6: Diagnosis Criteria for PCOS
Diagnosis Criteria
National Institute of Child Health and Human Development (1990):
Menstrual irregularity
Hyperandrogenism (clinical or biochemical)
ESHRE-ASRM (2003):
Menstrual irregularity
Hyperandrogenism
Polycystic ovaries on ultrasound (at least 2 of 3 criteria required)
AEPCOS Society (2006):
Hyperandrogenism (clinical or biochemical)
Menstrual irregularity
Polycystic ovaries on ultrasound (either or both)
NIH Workshop (2012): Endorsement of the Rotterdam criteria with recommendations for exclusion of other hormonal disorders.
Exclusions
Exclude conditions like non-classic adrenal hyperplasia, Cushing's syndrome, androgenic tumors, hyperprolactinemia, and thyroid disease.
Page 7: Ultrasound Criteria for Diagnosis
Classic definition requires 12 or more peripherally oriented cystic structures (2 to 9 mm) in at least one ovary.
Evolving criteria now recommend follicle number per ovary (FNPO) being most diagnostic: FNPO should be 19 to 20.
Ovarian volume of 10 mL or more is also a diagnostic parameter.
Page 8: Ovarian Morphology in PCOS
Antimüllerian hormone (AMH):
Value > 4.7 ng/mL can be a marker for polycystic ovaries but is not diagnostic on its own.
Polycystic appearing ovaries (PAO) are common in 10% to 25% of the normal reproductive-age population without PCOS symptoms.
Isolated findings of polycystic ovaries should not be mistaken for PCOS diagnosis but might indicate risk factors.
Page 9: PAO Insights
Not all women with isolated polycystic ovaries are diagnosed with PCOS.
Up to 20% of girls may have polycystic ovaries during adolescence.
The transition from normal to polycystic morphology may be influenced by genetics or environmental factors.
Page 10: Development of PCOS
Women with polycystic appearing ovaries (PAO) may have normal menstrual cycles and androgen levels but can later develop PCOS under susceptibility factors.
Page 11: Susceptibility Factors in PCOS Development
Heightened susceptibility due to genetic, environmental, or endocrine factors can lead to developing PCOS later in life.
Page 12: Menstrual Irregularity
Menstrual irregularity encompasses oligomenorrhea and amenorrhea with abnormal cycles indicating ovulatory issues. This is a strong correlate with insulin resistance in PCOS.
Page 13: Hyperandrogenism
Symptoms of excess include hirsutism, acne, and alopecia.
Blood tests may show normal levels of testosterone despite symptoms, complicating diagnoses.
Page 14: Androgens in PCOS
11-oxygenated androgens from adrenal glands are significant, affecting lipid metabolism and insulin resistance in women with PCOS.
Page 15: Assessment of Hirsutism
Hirsutism is evaluated using the modified Ferriman-Gallwey score; ethnic variations affect expressions of hyperandrogenism.
Page 16: Ferriman-Gallwey Scoring
The scoring system rates hair growth in nine body areas on a scale from 0 to 4. A score ≥6 typically indicates hirsutism.
Page 17: Phenotypes of PCOS
Different Phenotypes
Type A: Hyperandrogenism + Chronic anovulation + Polycystic ovaries.
Type B: Hyperandrogenism + Chronic anovulation.
Type C: Hyperandrogenism + Polycystic ovaries.
Type D: Chronic anovulation + Polycystic ovaries.
Page 18: Hyperandrogenism + Oligo-ovulation
Emphasizes hormonal disturbances associated with various types of PCOS.
Page 19: Phenotypic Diversity
Redefining PCOS based on its diverse presentations such as hyperandrogenism and irregular menses.
Page 20: Characteristics of Non-Hyperandrogenic PCOS
Non-hyperandrogenic type with irregular menses and polycystic ovaries counts as Type D.
Page 21: Endocrine Findings in PCOS
Key Findings
Abnormal gonadotropin secretion.
Elevated LH levels linked to obesity in PCOS.
Page 22: Gonadotropin Characteristics
Increased sensitivity to GnRH leads to elevated LH levels and abnormal LH/FSH ratios.
Page 23: Diagnosing PCOS
Elevated LH/FSH ratio has limited specificity for PCOS diagnosis and should not be solely relied upon.
Page 24: Estradiol in PCOS
High levels of biologically active estradiol arise from low SHBG levels, contributing to the risk of endometrial hyperplasia.
Page 25: Androgens in PCOS Risk Assessment
Measuring total testosterone, DHEAS, and conversion rates to DHT provides insights into symptomatology and risk factors associated with hirsutism.
Page 26: Elevated Prolactin Levels
About 20-30% of women with PCOS may show elevated prolactin levels related to increased GnRH pulsatility.
Page 27: Pathophysiology Overview
Major Pathways in PCOS
Ovulatory dysfunction
Disordered gonadotropin release
Insulin resistance
Page 28: Genetic and Environmental Factors
Genetic susceptibility and environmental factors contribute to the complexity of PCOS pathogenesis.
Page 29: Disordered Gonadotropin Release
Increased LH secretion impacts ovarian androgen production.
Page 30: Ovulatory Dysfunction
PCOS leads to disrupted follicle growth due to several hormonal disturbances.
Page 31: Insulin Resistance Impact
Insulin resistance exacerbates hormonal derangements, impacting normal biochemical processes and cycle regularity.
Page 32: Effects of Insulin Resistance
Insulin directly influences testosterone levels and follicle development.
Page 33: Overproduction of AMH
Excess AMH can interfere with FSH action in small follicles, promoting follicular arrest.
Page 34: Insulin Resistance Details
Both genetic predisposition and lifestyle factors contribute significantly to the development of insulin resistance in PCOS.
Page 35: Insulin Signaling Abnormalities
Lower levels of IGFBP enhance bioavailability of IGF-1, stimulating ovarian activity and androgen production.
Page 36: Role of Adipose Tissue
Adipostatic changes contribute to further insulin resistance and metabolic dysfunction.
Page 37: Assessing Insulin Resistance
Diagnostic focus on ruling out diabetes, evaluating glucose tolerance, and tracking fasting glucose and insulin levels.
Page 38: Measurement Techniques
Various indices (e.g., HOMA-IR, QUICKI) help evaluate insulin sensitivity effectively.
Page 39: Acanthosis Nigricans
Present in obese, hyperandrogenic PCOS patients, denoting severe insulin resistance and heightened metabolic concerns.
Page 40: PCOS Pathophysiology Summary
PCOS is characterized by androgens, insulin resistance, and hormonal imbalances leading to various symptoms.
Page 41: Consequences of PCOS
Changes in health focus from reproductive to long-term metabolic outcomes.
Page 42: Multi-disciplinary Approach
Treatment necessitates collaboration among specialists in various fields addressing comprehensive health aspects.
Page 43: Weight and Metabolic Issues
Overweight exacerbates risks associated with PCOS. Standardized diagnostic criteria for metabolic syndrome applicable to evaluate associated risks.
Page 44: Diabetes Correlation
Rates of Type 2 diabetes are notably elevated in PCOS populations; screening is critical.
Page 45: Quality of Life Concerns
PCOS affects emotional well-being and can exacerbate mental health issues due to physical and reproductive challenges.
Page 46: Cardiovascular Risk in PCOS
Identification of increased cardiovascular risk factors in patients with traditional PCOS presentations.
Page 47: Cardiovascular Findings
Evaluation of lipid profiles and traditional risk factors for cardiovascular diseases in PCOS patients.
Page 48: Cardiovascular Risk Pattern
Milder phenotypes generally demonstrate reduced cardiovascular risks compared to classical presentations of PCOS.
Page 49: Cancer Risks
Increased risk of endometrial and ovarian cancers associated with long-term hormonal imbalances in PCOS.
Page 50: Cancer Management in PCOS
Management strategies involving oral contraceptives can normalize cancer risks enhanced by PCOS.
Page 51: Ovarian Aging and PCOS
Consequential risks heighten with aging; constant monitoring and management procedures are crucial.
Page 52: Treatment Overview
Tailored treatments based on individual complaints related to symptoms and concerns posed by PCOS.
Page 53: Treatment Goals
Management should include lifestyle changes and symptom-specific treatments to effectively mitigate PCOS symptoms.
Page 54: Lifestyle Modification
Emphasizing lifestyle interventions significantly impacts managing all aspects of PCOS.
Page 55: Androgen Excess Management
Treatments primarily include oral contraceptives or anti-androgen medications to counteract excessive androgen effects.
Page 56: Management of Irregular Bleeding
Progestogen therapy is crucial for preventing endometrial complications in anovulatory women.
Page 57: Progestogen Therapy Scheduling
Regimen includes cyclical dosing to manage endometrial health in PCOS patients.
Page 58: Ovulation Induction for Infertility
Medications and lifestyle changes should be aligned for effective fertility restoration in PCOS.
Page 59: Fertility Treatments
Options for ovulation induction include several pharmacological agents and procedures tailored to individual patient needs.
Page 60: Treatment for Fertility Challenges
Adjunct therapies may be required if first-line treatments do not yield success.
Page 61: IVF Considerations
While effective, managing potential risks like OHSS is essential during IVF treatment for PCOS patients.
Page 62: Metabolic Management Strategies
Comprehensive lifestyle and dietary changes complement pharmacological approaches for managing metabolic risks.
Page 63: Surgery for Obesity Management
For individuals who are morbidly obese, bariatric surgery may be indicated as part of treatment.
Page 64: Summary of Treatment Modalities
Table outlining specific treatments for infertility, skin manifestations, abnormal bleeding, and metabolic concerns in PCOS.
Page 65: Final Summary
Overview of critical key points on diagnosis, resistance, hypertension, pathophysiology, consequences, and treatment of PCOS.
Page 66: Thank You
Acknowledgment to the audience for their attention.