NEWSLETTER
Polycystic Ovary Syndrome
Uzma Majid, Endocrine fellow, AKUH
Polycystic ovary syndrome (PCOS) is the most frequently encountered endocrine disturbance in premenopausal women affecting all ethnic groups. It is not only a reproductive disorder but a metabolic one.
DIAGNOSIS:
Two diagnostic criteria have been developed to identify and diagnose all patients with PCOS:
- National Institutes of Health (NIH) criteria — In 1990, the National Institutes of Health (NIH) Conference on PCOS defined PCOS as chronic, unexplained hyperandrogenism (either clinical or biochemical finding) and menstrual dysfunction.
- Rotterdam criteria — In 2003, a newer definition of the syndrome's phenotype was adopted at the Rotterdam PCOS Consensus Group Conference define PCOS when two of the three primary features are present; polycystic ovaries on ultrasonography, absent or irregular menstrual cycles, and/or clinical or biochemical signs of unexplained hyperandrogenism
PATHOGENESIS
The pathogenesis of the PCOS seems to be a multigenic disorder. Many candidate genes for PCOS have been proposed. In addition, several alternative hypotheses have been proposed for the pathogenesis, including
1. Hypothalamic-pituitary abnormalities that result in gonadotropin-releasing hormone and luteinizing hormone dysfunction leading to increased ovarian androgen biosynthesis.
2. A primary enzymatic defect in ovarian or combined ovarian and adrenal steroidogenesis.
3. A metabolic disorder characterized by insulin resistance in conjunction with compensatory hyperinsulinemia that exerts adverse effects on the hypothalamus, pituitary, ovaries, and adrenal glands.
CLINICAL MANIFESTATIONS
The most common clinical features include menstrual dysfunction or infertility, hirsuitism, acne, alopecia, visceral (android, central) fat distribution and obesity, sleep apnea, non alcoholic steatohepatitis, acanthosis nigricans and skin tags. Women with PCOS are at increased risk for type 2 DM, but an excess risk of cardiovascular disease has not yet been demonstrated definitively.
LABORATORY TESTING
In women suspecting to have PCOS should have done these medical laboratory tests including testosterone, sex hormone binding globulin (SHBG), and in addition DHEAS, 17 hydroxycorticosteroid progesterone, thyrotropin and prolactin to exclude other conditions. A-24 hour urine cortisol or cosyntropin stimulation test might also be done if clinically indicated. Transvaginal ultrasonography should be done if patient wishes to conceive or if other diagnostic criteria for PCOS are not present. Once a diagnosis of PCOS has been established, it is important to identify and monitor for abnormal glucose tolerance and other features of the metabolic syndrome.
TREATMENT:
Lifestyle modifications with pharmacotherapy are all helpful in managing PCOS patients. Pharmacologic therapy should be individualized and based on the particular patient's metabolic, gynecologic, and cosmetic concerns. Hirsutism can be treated by removal of hair by mechanical means such as shaving, waxing, depilatories, electrolysis or laser.
Lifestyle modification
Moderately intense aerobic exercise daily for 30 to 60 minutes is recommended. A target of 7% to 10% weight loss during the first year is an appropriate goal. Weight reduction reduces hyperinsulinism and its impact.
Restoring the menstrual cycle
Oral contraceptives are helpful for restoring normal menstrual cycle and treating functional ovarian cysts, reducing ovarian volume, and androgen production. Other benefits include the suppression of unopposed estrogen stimulation of the endometrium in anovulatory women. They also increase hepatic production of SHBG. The estrogenic component of the oral contraceptive suppresses LH, resulting in decreased ovarian androgen production.
Insulin-sensitizing drugs in the treatment of polycystic ovary syndrome
Include Metformin and Thiazolidinediones that affect ovarian steroid synthesis and improve the chances of ovulation, reduce free testosterone levels, increase levels of SHBG, reduce levels of PAI-1 and improve glycemia. Both have proven beneficial in reducing the risk of progression to T2DM.
Anti-androgen treatment in polycystic ovary syndrome
Spironolactone possesses moderate anti-androgenic effects when doses of 100 to 200 mg per day are used. Patients who desire cosmetic improvements may be treated successfully with a combination of oral contraceptives and spironolactone. The drug's effects may not become clinically apparent for up to 6 to 9 months.
Eflornithine hydrochloride, an inhibitor of the enzyme ornithine decarboxylase in human skin, has been approved for topical use in treating facial hirsutism. 5-Alpha-reductase inhibitors (Finasteride) and Flutamide which is a nonsteroidal pure anti-androgen are not approved by the FDA for treating hirsutism in patients who have PCOS.