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Fifth stage
Gynecology
Lec-5
.د
اسماء
13/4/2016
Polycystic ovary syndrome
The student at the end of this lecture should be able to:
Enumerate the diagnostic criteria for PCOS.
Describe it’s clinical presentation.
Describe the underlying hormonal changes .
Describe the ultrasounic features diagnosing PCOS.
Predict the life long risk for PCOS.
Differentiate PCO from PCOS.
Describe the available options for treating the presenting problems.
Poly cystic ovary syndrome:
Is a heterogeneous collection of symptoms and signs .
It's diagnosed by the presensce of two out of the following three criteria:
oligo and /or anovulation.
Hyperandrogenism clinically or biochemically.
Polycystic ovaries by transvaginal ultrasound.
Incidence:
In general,1-4% of women in the reproductive age suffer from PCO.
It’s the commonest endocrine disorder in women, prevalence(15-20%).
Inheritance:
It runs in families and affect approximately 50% of 1
st
degree relatives suggest dominant
inheritance
Clinical presentations of PCOS:
-no symptoms
-menstrual irregularities and dysfunction ranging from
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oligomenorrhoea to amenorrhoea , about 30% have normal cycle,50%have
oligomenorrhoea and 20% have amenorrhoea. Even in patient with regular cycle with
hyperandrogenism the rate of anovulation is 21%.
-hyperandrogenism : hirsutism ,acne ,alopecia ,but not virilism.
-obesity (10-65%):central type with higher waist to hip ratio .
-recurrent miscarrige:its relation to PCOS has been recently questioned.
-insulin resistance and hyperinsulinemia .
-impaired glucose tolerance test(1/3 of obese PCOS patient have impaired glucose
tolerance test and 7.5% to 10% have type 2 diabetes.
-abnormal lipoprotein are common in PCOS(elevated total cholesterol, triglyceride, LDL,
and low level of HDL.
Pathophysiology and labrotory finding:
Hyperandrogenism and anovulation in PCOS is caused by endocrine abnormality mainly in
the ovary with the total testosterone level is usually not more than twice the upper normal
range(20-80 ng/dl).
High intraovarian androgen concentration inhibit follicular maturation.
E1 level is increased as a result of peripheral aromatization of hyperandrogenisim .
There is abnormal estrogen feed back at the hypothalamic pituitary gland result in elevated
LH and LH:FSH ratio and exhibit elevated prolactin level in 25% of patients.
PCOS patient insulin resistance and compensatory hyperinsulinaemia as a result of PCOS
and obesity. Insulin is a potent stimulus for insuline secretion of androgen by the ovary by
the presence of different type of receptor doesn’t exhibit insulin resistance also it suppress
the synthesis of SHBG by the liver thus elevate the free androgen index. Patient are at
increased risk of glucose intolerance or frank diabetes.
Long term risk for patients with PCOS:
Persistently elevated level of estrogen uninterrupted by progesterone increase the risk of
endometrial cancer, breast cancer and ovarian cancer.
Obesity and metabolic abnormality and increase of plasminogen activator inhibitor cause
reduced fibrinolysis all are risk factors for the development of ischemic heart disease (7 fold
increase in MI) ,hypertention and dyslipidaemia .
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Insulin resistance and hyperinsulinaemia make the patient at risk of diabetes and
gestational diabetes later on in life.
During subsequent pregnancy there is increased risk of abortion ,gestational diabetes ,and
pre-eclampsia.
There is also increased morbidity in obese PCOS who fails to reduce their weight.
Diagnostic investigation:
Ultrasound: increased stromal thickness and increased ovarian volume (>10 cm3)(specific
for PCOS),and the presence of 12 or more follicles measured 2-9 mm in diameter.
Serum endocrinology:
Increase serum LH
Increase serum LH : FSH ratio
Increase serum androgen (testosterone and androstenedione)
Decrease SHBG
Increase estradiol and estrone (not measured routinely as Very wide rang of values).
Increase serum prolactin.
Increase serum insulin level.
Impaired glucose tolerance .
Management of PCOS:
The clinical management of PCOS should be focused on the individual problems
Obesity : obesity worsen the symptoms and the endocrine profile so obese women (BMI
>30 kg/m2) should reduce their weight and modify their life style by diet modification ,
increase exercise , stop smoking.
Menstrual irregularities:
low dose combined oral contraceptive preparation.
Progesterone as medroxy progesterone acetate (provera) Or dydrogesterone
(duphastone) for 12 days every 1-3 months to induce withdrawal bleeding.
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Hyperandrogenism and hirsutism :
A standirized scoring system as the modified Ferriman and Gallway score may be used to
evaluate the degree of hirsutism before and during treatment .
Physical treatment : electrolysis, waxing and bleaching, Laser and photothermolysis may be
helpful while waiting the effect of medical treatment.
Medical treatment : stop further progression and decrease the rate of hair growth.
Adequate contraception is important during treatment as antiandrogen disturb the
development of male genital tract:
First line is diane (ethinylestradiol 30 Mg with cyproterone acetate 2mg.CPA may cause
liver damage
So require regular checking and once response is achieved we should be switched to COCP
because diane can increase the risk of thromboembolism.
Spironolactone is a weak diuretic with antiandrogenic properities can be used at a daily
dose of 25-100 mg .
Other antiandrogen as Ketoconazole ,Finasteride and Flutamide (not used because their
side effect and they are no more effective thane CPA
Treatment of infertility in PCOS:
1. life style modification including diet reduction and exercise. A loss of 5-10% of body
weight in obese PCOS patients improve the prospect of both spontaneous and drug induced
ovulation
2.Medical Induction of ovulation in PCOS patient
by a. antioestrogen : - clomiphene citrate .
- Tamoxifene.
Clomiphene citrate : is an orally active synthetic non steroidal compound with oestrogenic
and non oestrogenic properties.
It displace the oestrogen from it’s receptor at the hypo-thalamic pituitary axis reduce it’s
negative feed back and encourage GnRH secretion.
It’s administered at 50 mg daily dose on day 2-6 of a spontaneous and induced menstrual
cycle (increased by 50 mg /day till ovulation occur for a max. Dose.
A course of 6-12 cycles can be used in women who respond to treatment with monitoring
by ultrasound for follicular response.
Ovulation is expected in 80% and pregnancy in 40% .
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Adverse reaction to such treatment:
-Antioestrogenic side effect including thickening of the cervical mucos and hot flushes in
10% of women.
-abdominal pain ,nausea , vomiting .
-headache and visual disturbance.
-breast tenderness.
-reversible hair loss.
-ovarian enlargement, and ovarian hyperstimulation syndrome is rare in <1%.
-Multiple pregnancy in 10%.
-Ovarian cancer described in women receive treatment for more than 12 cycles.
Tamoxifen:
has structure similar to clomiphene .the recommended dose is 20- 40 mg per day from day
3 for 5 days it have the same pregnancy rate as clomiphene with less potent
antioestrogenic action on the cervical mucos.
b. Medical induction by gonadotrophin :
Gonadotrophin are used when the patient do not respond to clomifene or fails to conceive
after 6-12 ovulatory cycles.
Preperation in common use include recombinant FSH or purified urinary human
menopausal gonadotrophin (FSH and LH). Gonadotrophin treatment result in cumulative
Pregnancy rates of 40-50% and 1-2% rate of OHSS.
c. GnRH analogues in ovulation induction : it’s used
in conjunction with gonadotrophin to achieve pituitary down regulation to facilitate cycle
control
d. Metformin : this is an oral biguanide inhibits the production of hepatic glucose ,enhance
the sensitivity of peripheral tissue to insulin thus decrease the secretion of insulin and treat
hyperinsulinaemia.
Metformin is shown to decrease hyperandrogenism and abnormalities of gonadotrophin
secretion and can restore menstrual cyclicity and fertility.
The usual dose is 850 mg bid or 500 mg t.d.s. taken Before meal .
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Side effect of metformin: nausea ,vomiting , flatulance and diarrhoea . (these can be
reduced by taking the drug before the meal and by gradually increasing the dose start with
850 mg nocturnal then 850 mg bid for the next week.
Metformin is not usually cause Lactic acidosis in non diabetic patient with PCOS with
normal liver and renal Function.
Regular checking of renal and liver function, metformin should discontinued for 3 days after
iodine containing compound and should be discontinued during pregnancy (although there
is no evidence of Teratogenesis).
3. Surgical method of ovulation induction
Laparoscopic ovarian diathermy LOD: by diathermy or Laser, it appear to be more
successful in a slim patient with high LH level. A unipolar coagulating current is used to
deliver four punctures to a depth of 4 mm in each ovary .The principle advantage of ovarian
drilling is monofollicular ovulation resulting in fewer multiple pregnancy rate with the
cumulative pregnancy rate similar to those obtained with 3-6 cycle of gonadotrophin.
LOD has replaces the wedge resection of the ovaries as it result into extensive peri-ovarian
and peritubal adhesion.