Polycystic%20ovarian%20syndrome Signs and Symptoms

• 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
• Irregular menstrual cycles may present as: 
  • Normal in the 1st year after menarche during pubertal transition
  • 1 to <3 years after menarche: <21 or >45 days
  • 3 years after menarche to perimenopause: <21 or >35 days or <8 cycles/year
  • 1 year post menarche >90 days for any 1 cycle
  • Primary amenorrhea by 15 years old or >3 years after thelarche (breast development)
• If clinical signs of hyperandrogenism (particularly hirsutism) are absent or unclear, assess biochemical hyperandrogenism to establish PCOS and/or phenotype 
• Pathogenesis involves ovarian steroidogenesis and follicular development abnormalities

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

Hyperinsulinemia

• 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 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

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)
  • 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, anovulation, or infertility
• Anovulation may present as frequent bleeding at <21-day intervals or infrequent bleeding at >35-day intervals

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

• Age (reproductive age)
• Genetics
• Ethnicity or race (hirsutism is milder in East Asians than in Europeans)
• Presence of other conditions, eg type 2 DM, dyslipidemia, nonalcoholic steatohepatitis, obesity, obstructive sleep apnea (OSA) and subclinical vascular disease