Makindo Medical Notes

Polycystic Ovary Syndrome (PCOS) is the most common cause of anovulation in young women, often leading to infertility and hirsutism.

About

• PCOS is the most common cause of infertility and hirsutism in women of reproductive age.
• It affects between 4-8% of women worldwide.
• The diagnosis is largely clinical, based on a combination of symptoms, blood tests, and imaging when necessary.

Aetiology

• PCOS is characterized by stromal hyperplasia in the ovaries, which leads to excess secretion of testosterone and other androgens.
• There is the formation of multiple follicular cysts in the ovaries, which disrupt normal ovulation.
• An imbalance of hormones is common, with an increase in Luteinizing Hormone (LH) and often associated with obesity and insulin resistance.
• It is also strongly associated with Metabolic Syndrome (Syndrome X), which includes insulin resistance, hypertension, and hyperlipidemia.

Clinical Features

• Obesity (though not always present) is common in women with PCOS.
• Irregular periods, including dysfunctional uterine bleeding or amenorrhoea.
• Signs of androgen excess such as acne, alopecia (especially male-pattern hair loss), and insulin resistance.
• Acanthosis nigricans (dark, velvety skin patches) and male-pattern baldness may also be observed.

Investigations

• Hormonal imbalances such as an increase in LH with normal or low FSH (follicle-stimulating hormone).
• Increased levels of Oestrone/Oestradiol, along with elevated Testosterone, DHEAS, and Androstenedione (androgens).
• Reduced sex hormone-binding globulin (SHBG), which contributes to higher levels of free androgens.
• In some cases, increased Prolactin levels may be observed.
• An Oral Glucose Tolerance Test (OGTT) is recommended to assess for diabetes or impaired glucose tolerance due to the high prevalence of insulin resistance in PCOS patients.
• An ovarian ultrasound may reveal the presence of multiple ovarian cysts, although this is not essential for diagnosis, as PCOS can be diagnosed without the presence of cysts.

Differential Diagnosis

• Congenital adrenal hyperplasia
• Prolactinoma
• Acromegaly
• Cushing's syndrome
• Ovarian and adrenal tumours

Management

• Weight reduction plays a critical role in managing PCOS, especially for obese patients, as it improves insulin resistance and hormonal balance. Referral to a dietician may be beneficial.
• Metformin is often prescribed to improve insulin sensitivity and may help restore ovulation, especially when combined with a low-calorie diet.
• For menstrual irregularities, progesterone therapy for 12 days every three months can induce a regular withdrawal bleed. Alternatively, the oral contraceptive pill with cyproterone acetate (an anti-androgen) can regulate periods and reduce hirsutism and acne.
• Clomiphene is used to induce ovulation in women who wish to conceive. This is often the first-line treatment for infertility in PCOS patients.
• The use of oral contraceptives (OCP) can suppress ovarian steroidogenesis and help manage symptoms like acne and hirsutism.
• Screening for diabetes is essential, particularly in overweight or obese patients, as they are at increased risk of developing type 2 diabetes.

Complications

• PCOS increases the risk of endometrial carcinoma due to prolonged unopposed estrogen exposure from anovulation.
• There is also an increased risk of developing diabetes mellitus and cardiovascular disease due to the associated insulin resistance and metabolic syndrome.