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Polycystic Ovary Syndrome

Polycystic Ovary Syndrome. Lianne Beck, MD Assistant Professor Emory Family Medicine. Overview. Prevalence and Pathogenesis Signs and Symptoms Diagnosis Treatment. Background. Stein & Leventhal 1935 Amenorrhea Infertility Hirsutism Enlarged polycystic ovaries. Prevalence.

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Polycystic Ovary Syndrome

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  1. Polycystic Ovary Syndrome Lianne Beck, MD Assistant Professor Emory Family Medicine

  2. Overview • Prevalence and Pathogenesis • Signs and Symptoms • Diagnosis • Treatment

  3. Background • Stein & Leventhal 1935 • Amenorrhea • Infertility • Hirsutism • Enlarged polycystic ovaries

  4. Prevalence • Most common hormonal and reproductive problem affecting women of child-bearing age • Present in 5-10% of women • Commonly under-diagnosed due to use of birth control pills

  5. Pathogenesis • UNKNOWN • High insulin levels • High androgen levels • High LH • Low estro/prog

  6. Pathogenesis • Genetics • Insulin-receptor substrate (IRS-1,IRS-2) • Calpain-5 • Calpain-10

  7. Signs and Symptoms • Pre-puberty • Increased levels of adrenal androgen • Increased insulin levels • Ovarian hyperandrogenism • Leads to precocious puberty

  8. Signs and Symptoms • Adolescence and Adulthood • Anovulation • Hyperandrogenism • Polycystic ovaries • Obesity-50% of women • Leads to reproductive disorders

  9. Signs and Symptoms • Late Adulthood • Diabetes • Hypertension • Dyslipidemia • Cardiovascular disease • Leads to metabolic effects

  10. Other Complications • Endometrial Cancer • Breast Cancer

  11. Clinical Features • Acne • Hirsutism

  12. Clinical Features • Acanthosis nigricans • Skin tags

  13. Clinical Features • Male-pattern alopecia • Central obesity

  14. Diagnostic Criteria • 1990 NIH criteria (all 3 must be met) • Hyperandrogenism, either clinical or biochemical • Menstrual irregularity (oligo- or anovulation) • Exclusion of other causes • Prolactinoma • Thyroid disease • Virilizing tumors of adrenal or ovarian tumors • Congenital adrenal hyperplasia • Cushing's syndrome

  15. Revised Diagnostic Criteria • 2003 Rotterdam Criteria • Presence of at least two of the following: • Oligo/anovulation • Hyperandrogenism • Polycystic ovaries on ultrasound • And the exclusion of other causes

  16. PCOS and Associated Lab Findings • Laboratory tests • Elevated androgen (i.e., testosterone) levels • Elevated LH with normal to mildly elevated FSH level • Insulin resistance with hyperinsulinemia • Glucose intolerance • Hyperlipidemia • Ultrasound findings • Multiple (nine or more) subcortical follicular cysts • Increased ovarian stromal density and/or volume

  17. Sonogram of PCOS The sonogram has a compact enlarged central stroma surrounded by multiple ( 12 or more) small cysts, of 2 to 9 mm in size.

  18. Urine HCG Prolactin level TSH Testosterone LH/FSH (3:1) Fasting insulin Fasting glucose, 2 hr GTT Fasting lipids Pelvic US* DHEAS* 17-OHP* Dexamethasone suppression test* Endometrial biopsy* Suggested Work-up of PCOS *--Suggested only in selected patients.

  19. Goals of Treatment • Decrease hyperinsulinism • Decrease hyperandrogenism • Induce ovulation • Prevent endometrial hyperplasia • Prevent metabolic complications • Weight loss

  20. Behavior Modification • Weight reduction • Diet and exercise • Decreases serum androgen, insulin and LH levels and improves lipid abnormalities

  21. First-Line Medications

  22. Second-Line Medications

  23. Patient Support • www.soulcysters.com • www.pcos.meetup.com • www.pcosupport.org

  24. Quiz • Which one of the following drugs occasionally used to treat hirsutism in polycystic ovary syndrome (PCOS) is U.S Food and Drug Administration pregnancy category X? A. Spironolactone (Aldactone) B. Metformin (Glucophage) C. Finasteride (Propecia) D. Flutamide (formerly Eulexin)

  25. Which one of the following drugs has the most data supporting its effectiveness in treating most manifestations of PCOS? A. Rosiglitazone (Avandia) B. Metformin C. Clomiphene (Clomid) D. Spironolactone

  26. Questions?

  27. References • American Journal of Gynecology. 1998. Dec:179 (6 Pt 2): S101 • Hunter MH. Sterrit JJ. Am Fam Phys 2000, vol. 62, no. 5 • Norman RJ. Wu R. Stankiewicz MT. Polycystic Ovary Syndrome. MJA 2004; 180 (3): 132-137. • Marrinan G. Stein M. Polycystic Ovarian Disease (Stein-Leventhal Syndrome. E-Medicine, May 24, 2005. • Radosh L. Drug Treatments for Polycystic Ovarian Syndrome. Am Fam Phys 2009, vol. 79, no. 8

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