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.

Introduction

  • Polycystic ovarian syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age and is characterized by menstrual abnormalities and clinical or biochemical features of hyperandrogenism

Biochemical Profile of PCOS

  • 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
    • Elevated serum concentrations of luteinizing hormone (LH)
    • Low to normal follicle-stimulating hormone (FSH)
    • Elevated testosterone and androstenedione
    • Low to normal estradiol while estrone level is increased
    • Elevated prolactin
    • Decreased sex hormone binding-globulin (SHBG)
    • Elevated insulin

Etiology

Hyperinsulinemia

  • Hyperinsulinemia is implicated as the major trigger for disordered ovarian function and androgen excess
  • May manifest clinically as part of a metabolic syndrome that includes dyslipidemia, diabetes mellitus (DM) and coronary artery disease (CAD)
  • Prevalence of DM is 7x higher in obese women with PCOS (fivefold higher in Asia), while the incidence of CAD is twofold to fivefold higher in the later years of PCOS patients
  • Increased insulin resistance, diabetes, and metabolic risks are seen in Southeast Asians 

Decreased Sex Hormone-Binding Globulin (SHBG)

  • Causes an increase in levels of free active androgens which accounts for the more marked hirsutism, acne and other manifestations of hyperandrogenism

Elevated Estrone

  • Stimulates hyperplasia of ovarian stroma theca cells, and the unopposed estrogen effects on the endometrium may lead to abnormal uterine bleeding and increased risk of endometrial cancer

Signs and Symptoms

Signs and Symptoms

Hyperandrogenism

  • May manifest clinically as:
    • Hirsutism (excessive growth of hair on androgen-sensitive areas of the skin such as the chin, upper lip, sideburns, sternal, periareolar, umbilical, sacral areas and more markedly on the pubic region and upper thighs)
      • Hirsutism is milder in East Asians
    • Severe cystic and persistent acne
    • Mild virilization
    • Rarely male-pattern alopecia 

Ovarian Dysfunction

  • May clinically manifest as menstrual disturbances: Primary amenorrhea or secondary amenorrhea (ie the absence of menses for >3 months after having had menses), oligomenorrhea, dysfunctional uterine bleeding, or infertility

Polycystic Ovaries

  • Either ≥20 follicles measuring 2-9 mm in diameter or increased ovarian volume (>10 cm3)

Other Signs That May be Present

  • Increased central adiposity and acanthosis nigricans are seen in Southeast Asians

Obesity

  • Central visceral obesity is present in 35-80% of patients
    • Obesity is usually not as severe in women of Mediterranean descent and is lower in East Asians

Hyperpigmentation

  • Found in skin fold creases
  • Acanthosis nigricans may also be observed in some patients
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