Polycystic Ovary Syndrome Diagnosis | Jindal IVF Chandigarh

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PCOD Diagnosis, Pathophysiology Clinical
Presentation as per age
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Definition

• PCOD is a syndrome arising from various
  etiologies leading to persistant anovulation (for
  a sufficient length of time) with clinical
  manifestations like hyperinsulinaemia androgen
  excess.
• 5-10 of reproductive age group women
• 40 of all women seeking infertility treatment
  have PCOS

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Diagnostic criteria

• NIH 1990 criteria
• Chronic anovulation
• Hyperandrogenaemia
• Exclusion of other factors like CAH,Cushings
  syndrome,androgen secreting tumours.
• AES 2006 Criteria Hyperinsulinaemia
• Chronic
  anovulation and/or Polycystic
• 
  ovaries
• Exclusion of
  other causes
• ASRM/ESHRE (ROTTERDAM) 2003 CRITERIA
  Oligo/Anovulation
  
  
  
• 
  Hyperandrogenaemia
  
• 
  Polycystic appearance
• 
  on U/S
• 
  (any 2 of above)

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Diagnosis of PCOD

• Rotterdam criteria- broader, includes two groups
  not covered in NIH criteria
• Patients with hyperandrogenism polycystic
  ovaries but normal ovulation
• Patients with hypo/anovulation polycystic
  ovaries but normal androgens

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Pathophysiology

• Ovaries
• Adrenal glands
• Peripheral (adipose tissue)
• HPO axis
• Genetic (Autosomal Dominant)

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Ovarian compartment

• Dysregulation of CYP17,the androgen forming
• enzyme in ovary causes
• Increased androstenedione testosterone
• Increased 17a-OHP
• Treatment with GnRH-a suppresses androgens
• Testosterone increases 2 fold (n- 20-80ng/dl)
• Ovarian Hyperthecosis causes 100 fold rise in
  serum testosterone

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Adrenal compartment

• Enzyme CYP17,responsible for 17a-OHlase 17,20
  lyase activation (progesterone ? testosterone) is
  hyperactive
• DHEAS is increased (produced exclusively by
  adrenal gland) and hypersensitive to ACTH
  stimulation (50 of cases)
• Onset of symptoms around puberty

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Periphery(Adipose tissue) in PCOD

• Obesity ass. with 35-60cases
• Increased peripheral aromatisation
• Decreased SHBG ? increased free levels of
  oestadiol testosterone
• Increased Insulin resistance ? increased androgen
• 5a-reductase nt in skin ? Hirsuitism
• 5-10 reduction in weight resumes ovarian function

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HPO axis in PCOD

• Decreased progesterone ? decreased opiod
  inhibition of Hypothalamus ?increased GnRH pulse
  frequency ? increased LH
• FSH not increased d/t negative feedback of
  elevated estrogen
• 25 have elevated prolactin levels (d/t abnormal
  estrogen feedback)

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Vicious cycle of PCOD
LH increases
Androstenedione increases

Testosterone increases
SHBG decreases
Estrone increase
Free estradiol increases
Endometrial cancer
Free testosterone increases
Hirsutism
Atresia
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Hyperinsulinaemia PCOD

• Android obesity fat in abdominal wall is more
  resistant to insulin.
• Inherent defects in insulin action insulin
  receptor disorders ? Hyperinsulinaemia
• Increased Insulin ? IGF-I,IGF-II receptors
  ?augments LH androgenisation of theca cells.

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Hyperinsulinaemia PCOD
Increased Weight Inherited defects in insulin
action Receptor disorders
LH increases
Increased Insulin
Theca cells (IGF-ll,IGF-l)
SHBG decreases
Androstenedione
Testosterone increases
Free Oestadiol increases
Estrone increases
Atresia
Hirsuitism
Endometrial Ca
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Metabolic syndrome/Syndrome X

• Insulin resistance obesity 3 or more of
• Hypertension gt130/85mm Hg
• Triglycerides gt150mg/dl
• HDLC lt50mg/dl
• Abdominal obesity - waist gt35 inches, waist/hip
  ratio gt0.85
• Fasting glucose gt110mg/dl

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Metabolic Syndrome PCOD

• Metabolic syn. is present in 2/3 of PCO patients
  (2 fold higher than women in general population)
• PCO is a comorbidity ass. with met.syn.
• Implications Increased carotid intima-media
  thickness ?Coronary artery disease
  Hypertension.

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Hormone Changes In PCOD

• LH increases, LHFSH reverses
• FSH decreases (negative feedback)
• Ovarian Increased Testosterone,androstenedione
• Estradiol- marginal increase
• Adrenal Increased DHEAS ,17aOHP
• Adipose tissue Estrone increases
• SHBG decreases

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Ultrasound picture of PCOD

• gt12 follicles at 2-9mm dia.(sensitivity
  75,specifity 99)
• Volume gt10cc
• If follicle is gt10mm,repeat scan next cycle
• Single ovary sufficient to diagnose
• Transvaginal is preferred

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SPECTRUM OF CLINICAL CONDITIONS ASSOCIATED WITH
PCOS
PCOS
ENDOMETRIAL CA
ANOVULATION
HYPERTENSION
DIABETES
INSULIN RESISTANCE
HIRSUITISM
ATHEROSCLEROSIS
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Clinical Presentation

• PUBERTY Hirsuitism,Acne(1/3 of pts)
• Delayed menarche
• Irregular menses
• Obesity(35-60)
• Physiological
  hyperinsulinaemia
• Acanthosis nigricans
• HAIR-AN syndrome
  

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Puberty PCOD

• Acanthosis nigricans marker of insulin
  resistance
• Hyperkeratosis papillomatosis
• Velvety brown thickened folds of skin
• Usual sites neck,groin,axilla

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Young women PCO

• Infertility (80-90 of anovulatory fertility)
• Oligo/Amenorrhoea (20-40)
• Obesity
• Hyperinsulinaemia
• Hirsuitism
• Pregnancy complications recurrent
  miscarriages(50),gestational diabetes,PIH,IUGR

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PCOD Mature women

• Type-ll Diabetes (5-10 fold)
• Hypertension (40)
• Cardiovascular problems
• Metabolic syndrome
• Endrometrial Ca (3 fold increase)
• Seizure disorders

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