W8 PCOS PDF - Polycystic Ovarian Syndrome

Lecture Material is adapted from © 2017 Wolters Kluwer Health, Lippincott Williams & Wilkins Applied Pathophysiology: A Conceptual Approach to the Mechanisms of Disease Chapter 14: Altered Reproductive Function Module 3: Clinical Models Copyright © 2017 Wolters Klu...

Lecture Material is adapted from © 2017 Wolters Kluwer Health, Lippincott Williams & Wilkins Applied Pathophysiology: A Conceptual Approach to the Mechanisms of Disease Chapter 14: Altered Reproductive Function Module 3: Clinical Models Copyright © 2017 Wolters Kluwer Health | Lippincott Williams &Wilkins Polycystic Ovarian Syndrome (PCOS)  Polycystic Ovarian Syndrome Pathophysiology Exact cause unknown Common cause of anovulation A condition of excess androgen production from the ovaries 1/10 women of childbearing age has PCOS >50% of woman with PCOS are obese Genetic link Those with PCOS more likely to have mother or sister with PCOS Excess androgen exposure results in: Multiple immature ovarian follicles Decreased progesterone production Increased acyclic (constant) estrogen production Anovulation Hirsutism and acne Obesity from conversion of androgens to estrogen in adipose tissues Hypertension, diabetes, obstructive sleep apnea  Polycystic Ovarian Syndrome Pathophysiology Reproductive cycle: regulated by changing hormone levels produced by the pituitary and by the ovaries In PCOS: altered level of gonadotropins (FSH, LH) LH (increased): the pituitary gland secretes high levels of LH the ovaries make excess androgens (ie. testosterone) converted to estrogen excess androgens prevents follicular development FSH (decreased, continued presence of small amount): follicle development continues but maturation of the follicles does not occur Chronic anovulation produces bilaterally distended and polycystic ovaries In the absence of ovulation: Marieb EN, Hoehn KN. Human Anatomy & Physiology. 9th ed. Boston, Pearson Education; 2013 estrogen alters GnRH resulting in high LH levels with elevation of androgen release and suppression of FSH The menstrual cycle is disrupted  Hyperinsulinemia and PCOS Relationship between high androgen levels and insulin resistance: Insulin excess promotes excessive androgen production by the ovaries Degree and frequency of hyperinsulinemia is amplified by obesity in woman Insulin sensitizing drugs have been shown to promote ovulation and, ultimately, pregnancy in some cases Anovulatory woman do not produce progesterone Unopposed estrogen environment in uterus Risk for endometrial hyperplasia, cancer  Polycystic Ovarian Syndrome Clinical Manifestations Clinical manifestations are associated with Menstrual irregularities Prolonged menstrual periods, and intervals, 50%) Lipid abnormalities Hypertension Acanthosis nigricans (darkened, thickened patches, velvety skin) Neck, armpits, inner thighs, vulva, hand, under breast http://www.nhs.uk/conditions/acanthosis-nigricans/Pages/Introduction.aspx Result of insulin resistance https://www.aad.org/public/diseases/color-problems/acanthosis-nigricans  Polycystic Ovarian Syndrome Diagnostic Criteria No definitive diagnostic test Clinical manifestations lead to suspected diagnosis Hormone level analysis Laboratory test to rule out other causes: Hyperprolactinemia Ovarian tumors, adrenal tumors Ovarian ultrasound: numerous small cysts Not enough for diagnosis Fasting cholesterol and triglyceride levels Hypercholesteremia Glucose tolerance test Level of insulin resistance McCance KL, Huether S. Pathophysiology. 7th ed. N.S.W, Mosby; 2015  Polycystic Ovarian Syndrome Treatment Goal of treatment: 1. suppress androgen production 2. manage clinical manifestations, symptomatic treatment, risk reduction If pregnancy is not desired: low-dose birth control pills to decrease androgen production and correct irregular bleeding progesterone: regulate menstrual periods, does not alter androgen levels If pregnancy is desired: Anti-estrogen medications to induce ovulation to achieve pregnancy Metformin improves ovulation Injectible gonadotropins Laparoscopic laser surgery of ovaries: puncture ineffective follicles may improve follicular function Symptom management: Obesity, high cholesterol, diabetes, hypertension to prevent long term CV risks