Polycystic Ovary Syndrome

Posted by • July 7th, 2016

2016-07-01_10-26-33The polycystic ovary syndrome is a disorder characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries.

The polycystic ovary syndrome increases the risk of infertility, endometrial cancer, abnormal glucose metabolism, and dyslipidemia. Strategies such as lifestyle modification, hair removal, and combined oral contraceptive therapy and other pharmacotherapies are reviewed. A new Clinical Practice summarizes.

Figure 1. Basic Pathophysiology of Hyperandrogenemia in the Polycystic Ovary Syndrome.

Clinical Pearl

• How are “polycystic ovaries” defined?

Polycystic ovarian morphologic features are currently defined as 12 or more antral follicles (2 to 9 mm in diameter) in either ovary, an ovarian volume that is greater than 10 ml in either ovary, or both. A transvaginal transducer with frequencies of 8 MHz or greater commonly detects an antral follicle count in this range in asymptomatic women (in ≥50% of asymptomatic women in some series), and some experts recommend a criterion with a higher antral follicle count (≥25) for sufficient specificity. Appropriate use of either criterion requires an experienced ultrasonographer; an unqualified report of “polycystic ovaries” is inadequate for diagnostic purposes. Ovarian ultrasonography is not required for diagnosis when both hyperandrogenism and ovulatory dysfunction are present.

Clinical Pearl

• How is the polycystic ovary syndrome diagnosed?

Three sets of criteria for the polycystic ovary syndrome in women have been developed. Each set involves different combinations of hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphologic features. The polycystic ovary syndrome is a diagnosis of exclusion. Nonclassic congenital adrenal hyperplasia can closely mimic this syndrome. An early-morning, early follicular-phase plasma level of 17-hydroxyprogesterone of less than 200 ng per deciliter effectively rules out 21-hydroxylase deficiency, which is the most common cause of nonclassic congenital adrenal hyperplasia. Androgen-secreting ovarian or adrenal tumors are rare, but they should be considered in patients with abrupt, rapidly progressive, or severe hyperandrogenism, marked hyperandrogenemia, or both.

Table 1. Diagnostic Criteria for the Polycystic Ovary Syndrome.

Morning Report Questions

Q: Name some of the conditions for which women with the polycystic ovary syndrome are at increased risk.

A: Among women with this syndrome, 50 to 80% are obese. Impaired glucose tolerance is reported in 30 to 35% of U.S. women with classic polycystic ovary syndrome, and type 2 diabetes mellitus is reported in 8 to 10%; the risk of these conditions is influenced by age, adiposity, and a family history of diabetes. Subclinical vascular disease (e.g., impaired endothelial function, increased carotid-artery intima–media thickness, and elevated coronary-artery calcium scores) has also been reported in women with the polycystic ovary syndrome and appears to be at least partly independent of adiposity. The risk of endometrial cancer is estimated to be 2.7 times as high among women with the polycystic ovary syndrome as among women without the syndrome, and the lifetime risk of endometrial cancer among women with the syndrome is 9%. Women with the polycystic ovary syndrome also have increased risks of pregnancy complications (e.g., gestational diabetes and preeclampsia), obstructive sleep apnea, and emotional distress (e.g., depression and anxiety).

Q: What are some of the general approaches to management of the polycystic ovary syndrome?

A: Treatment decisions are informed by patient priorities, the likely effectiveness and potential risks of available therapies, and whether the woman wishes to become pregnant. Typical therapeutic targets include hirsutism, irregular menses (and the risk of endometrial hyperplasia), and infertility. Mechanical hair removal (e.g., shaving and plucking) may be adequate to address hirsutism, but when pharmacologic therapy is needed, combined hormonal (estrogen–progestin) oral contraceptives are considered to be first-line agents. Other benefits of combined oral contraceptives include amelioration of acne, regular withdrawal bleeding that contributes to prevention of endometrial hyperplasia, and contraception. Oral spironolactone is an androgen-receptor antagonist that can reduce the growth of terminal hair. Spironolactone is typically used as an add-on therapy to combined oral contraceptives. Metformin reduces hyperinsulinemia and lowers serum testosterone levels by approximately 20 to 25% in women with the polycystic ovary syndrome. Metformin is recommended for women with the polycystic ovary syndrome and impaired glucose tolerance or type 2 diabetes that does not respond adequately to lifestyle modification. Clomiphene is generally considered to be the first-line agent for induction of ovulation in women with the polycystic ovary syndrome.

Table 2. Anticipated Effects of Common Therapeutic Options for the Polycystic Ovary Syndrome.

3 Responses to “Polycystic Ovary Syndrome”

  1. Alwin Lewis says:

    I’m shocked! The FIRST “general approach” to treating PCO should be weight loss. These other treatment modalities pale in comparison to weight loss’s ability to ultimately treat and control the entire metabolic cascade of PCO.

  2. Mariana says:

    🙂

  3. Hani ma says:

    Helpful in brief