Title: Polycystic Ovarian Syndrome
1Polycystic Ovarian Syndrome Hirsutism
- Walter Eisenhauer MMSc, PA-C
2Polycystic Ovarian Syndrome
- Formerly called Stein Leventhal Syndrome (1905)
- Characterized by
- anovulatory bleeding/amenorrhea
- hirsutism,
- obesity,
- hyperinsulinemia/insulin resistance,
- bilateral ovarian enlargement multiple cysts
- Infertility
- Hyperandrogenemia Hyperestrogenemia (due to
peripheral conversion)
3Polycystic Ovarian Syndrome
- Patients are obese and manifest insulin
resistance- frank diabetes is rare - Infertility75 of cases
- Hirsutism70 of cases
- Amenorrhea50 of cases
4Polycystic Ovarian Syndrome
- Pathophysiology
- incompletely understood
- abnormally elevated LH levels
- loss of mid cycle LH surge
- Excessive androgen production
- Atresia of ovarian follicles
- Ratio of LHFSH markedly increased
5Polycystic Ovarian Syndrome
- Inciting events are unknown and may differ from
one person to the next - Disturbance in hypothalamic-pituitary function is
postulated - Hyperinsulinism hyperandrogenism appear related
but incompletely defined
6Polycystic Ovarian Syndrome
- Affects 5 of reproductive age women
- Represents a leading cause of chronic anovulatory
bleeding - disorder of hypothalamic rhythmicity
- excessive LH production without mid cycle surge
- leads to overproduction of testosterone
Androstenedione
7Polycystic Ovarian Syndrome
- Androgens converted to estrone which causes
endometrial proliferation that results in
irregular periods - Serum concentrations of both estrogen and
testosterone rise - Insulin resistance once believed to be due to
ovarian androgen overproduction - Current theory is that Hyperinsulinism causes
ovarian androgen overproduction
8Polycystic Ovarian Syndrome
- Consequence of androgen overproduction
- hirsutism
- frank virilization
- Chronic unopposed estrogen stimulation leads to
endometrial Hyperplasia, cellular atypia, and
endometrial carcinoma
9Polycystic Ovarian Syndrome
- Risk of endometrial carcinoma increased threefold
10Polycystic Ovarian Syndrome
- History
- Complete a good menstrual history
- menarche
- duration, frequency, intensity of bleeding
- periods always irregular or new onset
- menorrhagia/metrorrhagia
- Sx of pregnancy
- Attempt to determine if irregular bleeding
ovulatory or anovulatory
11Polycystic Ovarian Syndrome
- History
- Ovulatory bleeding suggested by presence of
premenstrual symptoms - breast engorgement
- pelvic cramping
- fluid retention
- mood swings
- Menstrual regularity more suggestive of ovulatory
- Family Hx of PCO
12Polycystic Ovarian Syndrome
- Anovulatory
- absence of premenstrual symptoms
- frequently long periods of amenorrhea followed by
irregular bleeding
13Polycystic Ovarian Syndrome
- If bleeding thought to be anovulatory ask the
following - precipitated by emotional stress?
- Recent weight loss?
- Exercise?
- chronic illness?
- Rapid onset of hirsutism and virilization
suggestive of adrenal or ovarian tumor secreting
androgens
14Polycystic Ovarian Syndrome
- Life long history of irregular menses, hirsutism,
infertility, and obesity is suggestive of PCO
15Polycystic Ovarian Syndrome
- Physical Examination
- General
- seek s/s of virilization
- Skin
- changes suggestive of thyroid disorders
- Hair
- Neuro
- Pituitary tumors may cause bitemporal
hemianopsia, headaches other focal neuro findings
16Polycystic Ovarian Syndrome
- Pelvic
- ovarian enlargement-irregularity suggestive of
cysts - clitoral hypertrophy
- Breasts
- Galactorrhea
- Suggestive of hyperprolactinemia
17Polycystic Ovarian Syndrome
- Laboratory testing(the following may be elevated
and the only chemical evidence supporting PCO) - Estrone
- Androstenedione
- Free testosterone
- Pelvic Ultrasound
- use to detect polycystic ovaries
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19Polycystic Ovarian Syndrome
- Two hour post prandial glucose
- Lipid studies
20Polycystic Ovarian Syndrome
- Treatment
- Reduce risk of endometrial cancer by
administering monthly/bimonthly course of
medroxyprogesterone to induce menstrual bleeding - Infertility
- Old therapy wedge resection of ovaries (only
brings short term relief) - Still used
21Polycystic Ovarian Syndrome
- Treatment
- Infertility
- Clomiphene
- Prednisone
- Oral contraceptives
- spironolactone
- Hyperinsulinemia
- weight loss
- exercise
- oral hypoglycemics
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24Hirsutism
- Definition
- Increase in transformation from vellus to
terminal hair - Dont confuse with Non androgen dependent
increase in hair known as - Familial hypertrichosis
- vellus hair only
- face and trunk
- Managed by mechanical hair removal only
25Normal Hair Growth
- Hair grows cyclically not continuously
- Anagen-rapid growth
- Catagen-involution
- Telogen- resting stage
26Hirsutism
- Androgen dependent
- Male pattern hair growth
- respond best to combination therapy(hair removal
and meds) - 95 have both adrenal and ovarian causes
- PCO most common
27Hirsutism
- Causes of hirsutism
- Adrenal tumors
- Congenital adrenal hyperplasia
- Cushing's syndrome
- Medications (eg, Cyclosporine, anabolic steroids)
- Ovarian tumors
- Polycystic ovary syndrome
- Racial or ethnic background
28Hirsutism
- History
- Menstrual
- Family history
- Meds
- Endocrine review of systems
29Hirsutism
- Physical Examination
- General
- Endocrine
- Abdomen
- Pelvic
- Skin
30Hirsutism
- Lab evaluation
- Testosterone levels
- DHEA
- 24 hour free cortisol/dex suppression test
- Imaging studies of ovaries/adrenals
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33Hirsutism
- Guidelines for the Treatment of Hirsutism
- Polycystic ovary syndrome
- Oral contraceptives (Demulen 1/35, Desogen,
- Ortho-Cept, Ortho-Cyclen or Ortho Tri-Cyclen)
- Spironolactone (Aldactone), 50 to 100 mg two
times per day
34Hirsutism
- Idiopathic
- Oral contraceptives
- (Demulen 1/35, Desogen, Ortho-Cept, Ortho-Cyclen
or Ortho Tri-Cyclen) - Spironolactone, 50 to 100 mg two times per day
- Nonclassic
- Glucocorticoids prednisone, 5 mg every night
- Congenital adrenal hyperplasia
- dexamethasone, 0.25 mg every night at bedtime
- Cushing's syndrome
- Surgical excision of ACTH-secreting pituitary
35Hirsutism
- adenoma or ectopic ACTH-secreting tumor
- adrenalectomy for adrenal hyperplasia
- Adrenal tumor
- Surgical excision
- Ovarian tumor
- Surgical excision
- Drug-induced
- Discontinue medication
36Hirsutism
- Polycystic ovary syndrome
- Finasteride (Proscar), 5 mg per day, GnRH
agonist (Lupron Depot), 3.75 mg monthly - Idiopathic
- Finasteride, 5 mg per day