PCOS Case Discussion

» Definition of PCOS?

  • A condition in women characterized by irregular or no menstrual periods, acne, obesity, and excess hair growth due abnormal ovarian function and hyperandrogenism (abnormally elevated androgen levels)


» Pathophysiology of PCOS?

  • Factors related to genetics, obesity, sedentary lifestyle, intrauterine androgen exposure
    1. Insulin resistance -> acanthosis nigricans + hyperinsulinemia -> ↑ androgenic enzymes + ↓ SHBG
    2. Increased GnRH pulsatile release -> ↑ LH: FSH ratio -> theca cells -> androgen excess
      • free testosterone -> hirsutism, acne, alopecia
      • LH:FSH ratio and unopposed estrogen -> irregular menses, amenorrhea, anovulation, infertility and with time -> endometrial hyperplasia and risk of endometrial ca


 » Investigations of PCOS?

  • Labs:
    • Cycle d2-3 hormonal profile (FSH, LH, E2, TSH, testosterone, prolactin)
    • B-hCG
    • 17-hydroxyprogesterone (to r\o late-onset congenital adrenal hyperplasia)
    • 24-hr urine cortisol (to r\o Cushing’s)
  • US: showing multiple peripheral cysts (20-100 cystic follicles in each ovary) + stromal hyperplasia + thickened ovarian capsule


» Diagnosis of PCOS?

  • Based on Rotterdam criteria; 2 of 3:
    1. Menstrual dysfunction
    2. Hyperandrogenism, either clinically or biochemically
    3. Polycystic ovaries on US (≥ 12 peripheral cysts, 2-9 mm in diameter)
    4. With exclusion of other causes


» Treatment of PCOS according to symptoms?

  • For everything and everyone> life style modifications: quit smoking, weight loss, exercise
  • Irregular menses> OCP (progesterone component will prevent endometrial hyperplasia)
  • Hyperandrogenism (hirsutism, acne, alopecia) -> OCP (by suppressing LH stimulation of theca cells + inc SHBG), spironolactone (prevents peripheral conversion of androgens)
    • Hirsutism: physical measures (bleaching, waxing, electrolysis)
    • Acne: topical benzoyl peroxide, tretinoin cream
  • Insulin resistance -> metformin
  • Infertility -> metformin + ovulation induction: clomiphene citrate, human menopausal gonadotropin


» Prognosis\complications of PCOS?

  • Increased risk of cardiovascular and cerebrovascular diseases
  • Insulin resistance -> increased risk of T2DM
  • Increased of endometrial hyperplasia and endometrial Ca (no association w\ breast or ovarian ca)


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