polycystic%20ovarian%20syndrome
POLYCYSTIC OVARIAN SYNDROME
Polycystic ovarian syndrome (PCOS) is the accumulation of underdeveloped follicles in the ovaries due to anovulation. It is is characterized by menstrual abnormalities and clinical or biochemical features of hyperandrogenism.
It results mainly from abnormal steroidogenesis that may be caused by insulin resistance leading to hyperinsulinemia.
There is increased sensitivity to androgens and the majority of women have elevated androgen levels.

Diagnosis

  • Diagnosis is based on 2003 Rotterdam criteria:
    • 2 out of 3 of the following: Oligo-ovulation or anovulation, clinical or biochemical signs of hyperandrogenism, polycystic ovaries
    • Exclusion of other causes (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing’s syndrome, thyroid disease, prolactinoma)
  • Androgen Excess PCOS Society guidelines cite hyperandrogenism as an absolute requirement for diagnosis

History

  • Focus on the onset and duration of various signs of androgen excess, menstrual history and concomitant medications eg exogenous androgens
    • Menstrual history must screen for the status of ovulation in women with PCOS seeking fertility
  • Family history of DM or cardiovascular disease (CVD) (especially 1st-degree relatives with premature onset of CVD)

Physical Examination

  • Patients usually have features of hyperandrogenism and chronic anovulation; cutaneous symptoms of PCOS should be documented
    • Visual scales such as the modified Ferriman Gallwey score (mFG) for hirsutism and the Ludwig visual score for alopecia may be used during evaluation
  • Body mass index (BMI) and waist-hip ratio are calculated
  • Blood pressure

Laboratory Tests

  • Urine pregnancy test should be obtained in every patient in the reproductive age group reporting for menstrual abnormalities
  • If the patient presents with clinical features of hyperandrogenism with chronic anovulation, then other identifiable causes need to be excluded
  • Biochemical hyperandrogenism may be evaluated by measuring total or free testosterone or free androgen index using chromatography assays 
    • If total or free testosterone levels are not increased, consider measuring androstenedione and dehydroepiandrosterone (DHEAS), though additional information from these is limited
  • Patient should undergo lab tests to exclude:
    • Androgen-secreting tumors of the ovary or adrenal gland, late-onset congenital adrenal hyperplasia, and hyperprolactinemia
    • The above can be ruled out if prolactin, TSH, free testosterone, DHEAS and corticotropin-stimulated 17-α-hydroxyprogesterone levels are normal
  • Oral glucose tolerance test (OGTT) determines the degree of glucose tolerance and hyperinsulinemia 
  • Lipid profile
  • Midluteal serum progesterone may be done to document potential anovulation in PCOS patients with regular menses

Imaging

Ultrasonography

  • Used in the diagnosis of PCOS in patients who are 8 years past their menarche because a high incidence of multifollicular ovaries is seen in females with a gynecological age of <8 years 
  • Transvaginal ultrasound is the preferred approach if acceptable to the patient and if sexually active 
  • Determination of polycystic ovaries in one or both ovaries:
    • Endovaginal ultrasound findings of ≥20 follicles measuring 2-9 mm in diameter per ovary and/or increased ovarian volume (≥10 cm3) on either ovary; transabdominal ultrasound finding of an ovarian volume ≥10 cm3 due to difficulty of follicle counting
    • If there is a follicle >10 mm in diameter, the scan should be repeated at a time of ovarian quiescence in order to calculate volume and area
    • Presence of one polycystic ovary is sufficient to provide the diagnosis
  • Identification of endometrial abnormalities
    • Routine screening with ultrasound for endometrial thickness to rule out endometrial cancer in PCOS patients is not recommended
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