Poly cystic ovarian syndrome - Clinicals, Diagnosis, and Management

Sexual and Reproductive Health

Clinicals - History

Fact Explanation
Oligomenorrhoea/ Amenorrhoea Polycystic ovarian syndrome (PCOS) is defined as ovarian dysfunction associated with hyperandrogenism and polycystic ovarian morphology. PCOS is the commonest endocrinopathy among women of the reproductive age group and is characterized by metabolic derangement – hyperinsulinemia, hyperandrogenism and excess LH. The excess luteinizing hormone and insulin cause increased ovarian androgen production. These hormonal changes lead to anovulation and bleeding irregularities. Symptoms onset is usually in the late second and third decades. Oligomenorrhoea/ Amenorrhoea
Polycystic ovarian syndrome (PCOS) is defined as ovarian dysfunction associated with hyperandrogenism and polycystic ovarian morphology. PCOS is the commonest endocrinopathy among women of the reproductive age group and is characterized by metabolic derangement – hyperinsulinemia, hyperandrogenism and excess LH. The excess luteinizing hormone and insulin cause increased ovarian androgen production. These hormonal changes lead to anovulation and bleeding irregularities. Symptoms onset is usually in the late second and third decades.
Infertility PCOS is major cause of infertility especially in the developed countries. About 75% of patients’ with PCOS may complain of difficulty in conceiving. Anovulatory cycles lead to inadequate oocyte formation. Infertility
PCOS is major cause of infertility especially in the developed countries. About 75% of patients’ with PCOS may complain of difficulty in conceiving. Anovulatory cycles lead to inadequate oocyte formation.
Recurrent miscarriages PCOS is associated with 3-fold increase in the rate of spontaneous pregnancy loss. PCOS is also considered an important cause for recurrent miscarriage. The specific aetiology for miscarriage is not known. Factors implicated with pregnancy loss include obesity, insulin resistance, hyperandrogenism, polycystic ovaries and placental thrombosis. Recurrent miscarriages
PCOS is associated with 3-fold increase in the rate of spontaneous pregnancy loss. PCOS is also considered an important cause for recurrent miscarriage. The specific aetiology for miscarriage is not known. Factors implicated with pregnancy loss include obesity, insulin resistance, hyperandrogenism, polycystic ovaries and placental thrombosis.
Acne/ Excess hair growth / male pattern boldness Due to hyperandrogenism. Excess hair growth (hirsutism) mainly occurring in the face, chest and lower abdomen is a common symptom of PCOS and may in fact be the only symptom. Androgen secretion from the ovary is stimulated by LH and hyperinsulinaemia. Acne/ Excess hair growth / male pattern boldness
Due to hyperandrogenism. Excess hair growth (hirsutism) mainly occurring in the face, chest and lower abdomen is a common symptom of PCOS and may in fact be the only symptom. Androgen secretion from the ovary is stimulated by LH and hyperinsulinaemia.
Weight gain The excess fat mass in obese patients increase insulin resistance. The resulting hyperinsulinaemia contributes to weight gain which turn further worsens insulin resistance. This results in a vicious cycle. Weight gain
The excess fat mass in obese patients increase insulin resistance. The resulting hyperinsulinaemia contributes to weight gain which turn further worsens insulin resistance. This results in a vicious cycle.
Psychological impact Patients may have depressive symptoms and low self-esteem due to subfertility, hyperandrogenic features and irregular bleeding. Psychological impact
Patients may have depressive symptoms and low self-esteem due to subfertility, hyperandrogenic features and irregular bleeding.
Associations/Risk factors The aetiology of PCOS is still unknown. PCOS has a strong genetic predisposition. Obesity, hypertension, insulin resistance and metabolic syndrome are risk factors for the disease. Autoimmune thyroid disease may rarely be associated. Associations/Risk factors
The aetiology of PCOS is still unknown. PCOS has a strong genetic predisposition. Obesity, hypertension, insulin resistance and metabolic syndrome are risk factors for the disease. Autoimmune thyroid disease may rarely be associated.
History of hypertension, hyperlipidaemia and diabetes Look for risk factors for disease development. History of hypertension, hyperlipidaemia and diabetes
Look for risk factors for disease development.

Clinicals - Examination

Fact Explanation
General examination : Body mass index (BMI) / Waist to hip ratio Measurement of the BMI and waist to hip ratio is important. Obese patients require weight reduction interventions. General examination : Body mass index (BMI) / Waist to hip ratio
Measurement of the BMI and waist to hip ratio is important. Obese patients require weight reduction interventions.
General examination : Features of hyperandrogenism Inspect for hirsutism, acne and boldness. Thinning of scalp hair may also be noted. General examination : Features of hyperandrogenism
Inspect for hirsutism, acne and boldness. Thinning of scalp hair may also be noted.
General examination : Acanthosis nigricans A black discoloration and roughening usually observed at the back of the neck, axillae and other flexures. Acanthosis nigricans is associated with hyperinsulinaemia. This may appear before the onset of diabetes mellitus. General examination : Acanthosis nigricans
A black discoloration and roughening usually observed at the back of the neck, axillae and other flexures. Acanthosis nigricans is associated with hyperinsulinaemia. This may appear before the onset of diabetes mellitus.
Cardiovascular system : Hypertension Hypertension may be found as part of the metabolic syndrome. Cardiovascular system : Hypertension
Hypertension may be found as part of the metabolic syndrome.
Abdominal and vaginal examination Usually normal. Abdominal and vaginal examination
Usually normal.

Investigations - Diagnosis

Fact Explanation
Diagnosis depends on both clinical information and investigations Rotterdam criteria is used for diagnosis of PCOS. Two or more out of the following three criteria is required to diagnose PCOS. 1. A history of irregular bleeding due to anovulation – oligomenorrhoea, amenorrhoea, 2. Clinical or biochemical evidence of hyperandrogenism, 3. Ultrasonic features of polycystic ovaries. Diagnosis depends on both clinical information and investigations
Rotterdam criteria is used for diagnosis of PCOS. Two or more out of the following three criteria is required to diagnose PCOS. 1. A history of irregular bleeding due to anovulation – oligomenorrhoea, amenorrhoea, 2. Clinical or biochemical evidence of hyperandrogenism, 3. Ultrasonic features of polycystic ovaries.
Pelvic ultrasound scan – transvaginal scan. Polycystic ovaries are defined as 12 or more subcapsular follicles of <10mm diameter in an ovary or ovarian volume > 10ml. Pelvic ultrasound scan – transvaginal scan.
Polycystic ovaries are defined as 12 or more subcapsular follicles of <10mm diameter in an ovary or ovarian volume > 10ml.
LH, FSH levels The normal 1:1 ratio between concentrations of LH and FSH is lost in PCOS. In PCOS the LH concentration is usually elevated with a ratio of LH to FSH of 2:1 or 3:1. Assessment LH, FSH ratio is not essential for diagnosis. LH, FSH levels
The normal 1:1 ratio between concentrations of LH and FSH is lost in PCOS. In PCOS the LH concentration is usually elevated with a ratio of LH to FSH of 2:1 or 3:1. Assessment LH, FSH ratio is not essential for diagnosis.
Testosterone, androstenedione, Sex hormone binding globulin (SHBG) The concentration of androgens is usually elevated. The level of SHBG will be reduced. Testosterone, androstenedione, Sex hormone binding globulin (SHBG)
The concentration of androgens is usually elevated. The level of SHBG will be reduced.
Thyroid function test Rule out thyroid dysfunction which may present with menstrual irregularities and hyperandrogenism. Thyroid function test
Rule out thyroid dysfunction which may present with menstrual irregularities and hyperandrogenism.
Serum prolactin level Screen for hyperprolactinemia Serum prolactin level
Screen for hyperprolactinemia

Investigations - Management

Fact Explanation
Blood glucose test To identify the presence of diabetes. Patients with PCOS have a 5-10 fold risk of developing type 2 diabetes in future. Blood glucose test
To identify the presence of diabetes. Patients with PCOS have a 5-10 fold risk of developing type 2 diabetes in future.

Management - Supportive

Fact Explanation
Patient education The patient should be provided information regarding the natural course of the disease, aetiology, complication and treatment options available. It is important to address the patients’ main concerns. Patient education
The patient should be provided information regarding the natural course of the disease, aetiology, complication and treatment options available. It is important to address the patients’ main concerns.
Weight reduction Weight reduction is associated with significant improvement in menstrual symptoms. Life style modifications, dietary changes and regular exercise help reduce weight. Weight reduction
Weight reduction is associated with significant improvement in menstrual symptoms. Life style modifications, dietary changes and regular exercise help reduce weight.
Dietary modifications Dietary modifications should be made to reduce weight. Weight reduction improves menstrual irregularities and reduced the risk of diabetes and cardiovascular disease. Dietary modifications
Dietary modifications should be made to reduce weight. Weight reduction improves menstrual irregularities and reduced the risk of diabetes and cardiovascular disease.
Regular exercise Encourage aerobic exercises to reduce the weight. Regular exercise
Encourage aerobic exercises to reduce the weight.
Management of existing diabetes, hypertension and hyperlipidaemia Optimize pharmacological therapy for Diabetes, hypertension and hyperlipidaemia. Management of existing diabetes, hypertension and hyperlipidaemia
Optimize pharmacological therapy for Diabetes, hypertension and hyperlipidaemia.
Psychological support Management of PCOS is difficult and the symptoms may cause significant distress to the patient. Patients should be managed sensitively and motivation should be provided continuously. Specialist psychological support may be required. Psychological support
Management of PCOS is difficult and the symptoms may cause significant distress to the patient. Patients should be managed sensitively and motivation should be provided continuously. Specialist psychological support may be required.

Management - Specific

Fact Explanation
Managing menstrual dysfunction Combined oral contraceptive pill and cyclical progesterone is used to regulate menstruation. Contraceptive pills with anti-androgen effects (cyproterone acetate/co-cyprindiol- dianette) are used to control both menstrual irregularities and features of hyperandrogenism. Weight loss also improves regularity of menstruation. Managing menstrual dysfunction
Combined oral contraceptive pill and cyclical progesterone is used to regulate menstruation. Contraceptive pills with anti-androgen effects (cyproterone acetate/co-cyprindiol- dianette) are used to control both menstrual irregularities and features of hyperandrogenism. Weight loss also improves regularity of menstruation.
Treatment for hyperinsulinaemia Lifestyle modification with dietary changes and regular exercise is the most effective measure to control the effects of hyperinsulinaemia. Metformin is increasingly being used for management of PCOS patients with metabolic syndrome. Metformin has beneficial effects on regularizing the menstruation. Even though widely used, the evidence on the benefits of metformin is limited and controversial. Treatment for hyperinsulinaemia
Lifestyle modification with dietary changes and regular exercise is the most effective measure to control the effects of hyperinsulinaemia. Metformin is increasingly being used for management of PCOS patients with metabolic syndrome. Metformin has beneficial effects on regularizing the menstruation. Even though widely used, the evidence on the benefits of metformin is limited and controversial.
Management of subfertility Weight loss alone may improve spontaneous ovulation. Ovulation induction can be carried out with clomiphene. Use of Gonadotrophins is another management option if anti-estrogens fail. Metformin is currently not recommended for management of subfertility. In vitro fertilization may be required in patients who fail to conceive after medical therapy. Management of subfertility
Weight loss alone may improve spontaneous ovulation. Ovulation induction can be carried out with clomiphene. Use of Gonadotrophins is another management option if anti-estrogens fail. Metformin is currently not recommended for management of subfertility. In vitro fertilization may be required in patients who fail to conceive after medical therapy.
Management of hyperandrogenic features Hirsutism can be managed with topical therapy with Eflornithine cream or with oral therapy with Cyproterone acetate and metformin. GnRH analogues with low dose HRT, Finasteride and Spironolactone can be used in patients with severe symptoms. Cosmetic hair removal by shaving, depilatory cream, laser or electrolysis can also be carried out. Management of hyperandrogenic features
Hirsutism can be managed with topical therapy with Eflornithine cream or with oral therapy with Cyproterone acetate and metformin. GnRH analogues with low dose HRT, Finasteride and Spironolactone can be used in patients with severe symptoms. Cosmetic hair removal by shaving, depilatory cream, laser or electrolysis can also be carried out.
Surgical treatment Laparoscopic ovarian drilling can be tried to improve ovulation and chances of fertility. Surgical treatment
Laparoscopic ovarian drilling can be tried to improve ovulation and chances of fertility.

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