Polycystic Ovarian Syndrome

Snapshot

• A 31-year-old G0 woman presents with difficulty becoming pregnant. She reports trying to conceive a child for over a year; however, she has not been successful. Past medical history is significant for type 2 diabetes mellitus and obesity. On physical exam, there is acne and hair on the upper lip and chin. There is also acanthosis nigricans in the posterior neck. Blood tests reveal an elevated free testosterone level and LH:FSH of 3.

Introduction

• Endocrinopathy that can result in
  • ovarian dysfunction
    • can lead to primary or secondary amenorrhea and oligomenorrhea
      • prevents formation of the corpus luteum, impairing progesterone synthesis which leads to
        • unapposed estrogen proliferative effect on the endometrium that results in
          • bleeding
          • increased risk of endometrial hyperplasia and cancer 
  • hyperandrogenism
    • may present as acne and hirsutism
  • polycystic ovaries
• Pathogenesis
  • mechanism is unclear
    • peripheral insulin resistance leads to hyperinsulinemia
    • ovarian stimulation leading to excess androgen production
• Epidemiology
  • a common cause of infertility in woman of reproductive age
• obesity is a risk factor

Presentation

• Symptoms 
  • menstrual dysfunction
    • e.g., dysfunctional uterine bleeding and amenorrhea
  • infertility
  • hirsutism
  • acne
• Physical exam
  • obesity
  • hirsutism
  • acne
  • acanthosis nigricans 
• bilateral enlarged ovaries on pelvic exam

Evaluation

• Laboratory testing
  • total and free testosterone level
  • LH/FSH > 3 
• Pelvic ultrasound
• polycystic ovaries

Differential

• Cushing syndrome
• Non-classical congenital adrenal hyperplasia
• Androgen-secreting tumor
• Pregnancy
• Premature ovarian failure
• Thyroid disease
  • hyper- or hypothyroidism
• Prolactinoma

Treatment

• Medical therapy
  • obesity
    • life-style modification
      • diet and exercise
  • anovulation
    • hormonal contraceptives
      • first-line
      • also first-line for treating hirsutism
    • metformin 
      • second-line agent
  • infertility
    • clomiphene citrate
      • first-line
  • glucose intolerance
• metformin

Complications

• Complications
  • infertility
  • endometrial hyperplasia and cancer
  • associated with increased insulin resistance