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==Overview== | ==Overview== | ||
Revision as of 20:56, 3 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
PCOS is the most common form of chronic anovulation associated with androgen excess. Polycystic ovary syndrome occurs in approximately 5% to 10% of reproductive-age women. The diagnosis of PCOS is made by excluding other hyper androgenic disorders like nonclassic adrenal hyperplasia, androgen-secreting tumors, hyperprolactinemia in women with chronic anovulation and androgen excess. During the reproductive years, PCOS is associated with important reproductive morbidity, including infertility, irregular uterine bleeding, and increased pregnancy loss. The endometrium of the patient with PCOS must be evaluated by biopsy because long-term unopposed estrogen stimulation leaves these patients at increased risk for endometrial cancer. PCOS is also associated with increased metabolic and cardiovascular risk factors. These risks are linked to insulin resistance and are compounded by the common occurrence of obesity, although insulin resistance also occurs in nonobese women with PCOS. PCOS is considered to be a heterogeneous disorder with multifactorial causes. PCOS risk is significantly increased with a positive family history of chronic anovulation and androgen excess, and this complex disorder may be inherited in a polygenic fashion
Historical Perspective
PCOS was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal, from whom its original name of Stein–Leventhal syndrome is taken. The earliest published description of PCOS was in 1721 in Italy. Cyst-related changes to the ovaries were described in 1844
Classification
PCOS may be classified into 4 types based upon severity of symptoms into asymptomatic form, mild form, classical form and metabolic form
Pathophysiology
Causes
The underlying defect in patients with PCOS remains unknown, but the harmonal imbalance between LH, FSH and estrogen are mainly responsible for the development of polycystic ovary syndrome. Most studies suggest that more than one factor could play a role in developing PCOS.
Differentiating Polycystic ovary syndrome overview from Other Diseases
Polycystic ovary syndrome must be differentiated from other causes of irregular or absent menstruation and hirsutism, such as congenital adrenal hyperplasia, cushing's syndrome, hyperprolactinemia, and other pituitary or adrenal disorders.
Epidemiology and Demographics
Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders of reproductive-age women, with a prevalence of 4-12% in the United States. Up to 10% of women are diagnosed with PCOS.
Risk Factors
Common risk factors in the development of Polycystic ovary syndrome are hyperinsulinemia secondary to insulin resistance, obesity, family history of PCOS among first-degree relatives, premature adrenarche, fetal androgen exposure, and low birth weight
Screening
According to Royal College of Obstetricians and Gynaecologists (RCOG) thyroid function tests, serum prolactin levels, and a free androgen index are baseline screening tests recommended for women with suspected polycystic ovarian syndrome (PCOS).
Natural History, Complications, and Prognosis
If left untreated patients with PCOS can develop heart disease due to elevated cholesterol and increased levels of androgens. Increased lengths of time without a menstrual period leads to unopposed exposure of endometrium to estrogen can result in uterus cancer. Complications that can develop as a result of polycystic ovary syndrome are insulin resistance/type II diabetes, high blood pressure, dyslipidemia, strokes, miscarriage, and infertility. The prognosis for fertility in patients with polycystic ovary syndrome is good with treatment, unless there are other unknown fertility problems.
Diagnosis
Diagnostic Criteria
PCOS was previously defined according to the proceedings of an expert conference sponsored by the National Institutes of Health (NIH) in 1990, which described the disorder as including hyperandrogenism or hyperandrogenemia (or both), oligo-ovulation, and exclusion of known disorders of androgen excess and anovulation. Another expert conference held in Rotterdam in 2003 defined PCOS, after the exclusion of related disorders, by the presence of two of the following three features oligo-ovulation or anovulation, clinical or biochemical signs of hyperandrogenism (or both), and polycystic ovaries. In essence, the Rotterdam 2003 criteria expanded the NIH 1990 definition by creating two new phenotypes ovulatory women with polycystic ovaries plus hyperandrogenism and oligo-anovulatory women with polycystic ovaries but without hyperandrogenism.
History and Symptoms
The significant information that needs to focused in the history of the patient includes menstrual abnormalities, infertility, signs of virilization on physical examination and family history of PCOS among first-degree relatives.The most common symptoms of PCOS include amenorrhea or oligomenorrhea, abnormal uterine bleeding and androgenization, including hirsutism, acne, oily skin.
Physical Examination
Patients with polycystic ovary syndrome usually appear obese. During the physical examination, it is essential to search for and document signs of androgen excess (hirsutism, virilization, or both), insulin resistance (acanthosis nigricans), and the presence of unopposed estrogen action (well-rugated vagina and stretchable, clear cervical mucus) to support the diagnosis of PCOS
Laboratory Findings
Measurement of the plasma levels of several hormones is helpful in supporting the diagnosis of PCOS and especially in excluding other disorders. Determining the LH/FSH ratio of 3:1 is virtually diagnostic of PCOS. However, a normal ratio does not exclude the diagnosis, as LH levels fluctuate widely throughout the course of a day. Other androgens are measured to screen for other virilizing adrenal tumors. Fasting blood glucose is measured to look for diabetes, screening for lipid abnormalities is also employed. Testosterone is measured to exclude a virilizing tumor. Prolactin is measured to exclude a prolactinoma. Thyroid-stimulating hormone (TSH) is measured to rule out hypothyroidism.
Electrocardiogram Findings
There are electrocardiogram findings associated with polycystic ovary syndrome.
Abdominal X-ray Findings
There are no X-ray findings associated with polycystic ovary syndrome.
CT Findings
There are no CT findings associated with polycystic ovary syndrome.
MRI
There are no MRI findings associated with polycystic ovary syndrome.
Ultrasound Findings
The Rotterdam 2003 criteria include the use of ultrasound as a diagnostic tool in diagnosing PCOS. The typical polycystic-appearing ovary may emerge in a nonspecific fashion on an ultrasound. Multiple (12+) subcapsular follicles ranging from 2 to 9 mm in diameter in a state of arrested development ('pearl necklace' appearance) in a single ovary is diagnostic for PCOS on ultrasound.
Imaging Findings
There are no other imaging findings associated with polycystic ovary syndrome.
Other Diagnostic Studies
Endometrial biopsy is recommended in patients diagnosed with PCOS because long-term unopposed estrogen stimulation leaves these patients at increased risk for endometrial cancer.
Treatment
Medical Therapy
The first step in the management of PCOS is weight loss if the patient is obese, and treatment of type 2 diabetes with metformin. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating anovulatory cycling, either by stimulating ovulation or suppressing androgenic and ovarian activity. The selection of treatment depends on whether a pregnancy is desired. All anti-androgen treatments will take at least 3 months to affect hirsutism. The drug regimen for PCOS depends upon the desire for a pregnancy by the patient.
Surgery
Surgery is not considered first-line therapy for PCOS and it does not affect insulin resistance or obesity. Surgery is indicated in the treatment of PCOS only in patients desiring pregnancy in whom at least 1 year of conservative therapy has failed.
Prevention
There is no established method for prevention of PCOS.
Secondary Prevention
econdary preventive measures for PCOS include lifestyle modifications and use of metformin to prevent diabetes and atherosclerosis.