PCOS.pdf

Polycystic ovary Syndrome Dr. Ahmed Reda Lecturer in Obstetrics and Gynecology Background Ovulation is the result of a maturation process that occurs in the hypothalamic-pituitary-ovarian (HPO) axis and is controlled by a neuroendocrine cascade terminating in the ovarie...

Polycystic ovary Syndrome Dr. Ahmed Reda Lecturer in Obstetrics and Gynecology Background Ovulation is the result of a maturation process that occurs in the hypothalamic-pituitary-ovarian (HPO) axis and is controlled by a neuroendocrine cascade terminating in the ovaries. Imbalance of the hormones of the HPO axis manifest as anovulation Anovulation (definition): is the lack or absence of ovulation Anovulation is a not a disease but a sign, in much the same way that polycystic ovaries are the manifestation of a much larger disease process. Polycystic Ovarian Syndrome (PCOS) is the commonest cause of chronic anovulation.  Definition Chronic anovulation and hyperandrogenism in reproductive age females Cause Unknown Possible causes: Genetic Familial tendency Obesity Fetal programming  Pathophysiology PCOS is a condition that originates possibly at the time of puberty due to interplay of: Obesity and excess of ovarian androgen production: due to hyperinsulinemia & Insulin resistance. Intrauterine environment. Genetic factors: both X-linked, autosomal dominant inheritance. disturbance to hypothalamic-pituitary-ovarian axis. Abnormal Pituitary Function—Altered Negative Feedback Loop Increased GnRH from hypothalamus Excessive LH secretion relative to FSH by pituitary gland LH stimulates ovarian thecal cells-- androgen production Ineffective suppression of the LH pulse frequency by estrogen and progesterone Androgen excess increases LH by blocking the hypothalamic inhibitory feedback of progesterone  IR Obesity Insulin ovarian ILGF stimulation of androgen synthesis + theca cells LH Androgen - aromatase enzyme HI FSH E1  A vicious cycle, may start anywhere: Long-term 1ry CNS error  HP dysfunction stimulation of 1ry enzymatic error (ovary/adrenal) endometrium Long term risks of PCOS 1. Endometrial hyperplasia  carcinoma 2. Insulin resistance: Type II diabetes mellitus & hypertension 3. Dyslipidemia (HDL, LDL,  triglycerides)  coronary heart disease  Diagnosis Rotterdam criteria (ESHRE/ASRM):  the presence of 2 or more of: Oligo or anovulation and menstrual dysfunction. Clinical and/or biochemical hyperandrogenism. Ovarian size and morphology on ultrasound Anovulation and/or oligoovulation Androgen excess Adam's criteria = polycystic ovaries (by US) PCOS is a diagnosis of exclusion after eliminating other causes of anovulation (e.g. thyroid diseases and hyperprolactinemia) and other causes of androgen excess Adam's criteria: Ovarian volume > 10 cm3. Multiple follicles (≥ 10-12). Microcysts: ( 27 kg/m2 (in 50% of females with PCOS) Acanthosis nigricans = a velvety, darkening of the skin Bilateral enlarged ovaries Symmetrically enlarged uterus Treatment General measures: Stop smoking (as smoking increase adrenal androgen) Weight reduction: Effect = decrease insulin resistance  decrease hyper-insulinemia  decrease hyperandrogenism and decrease LH secretion. Oral hypoglycemic agents (may be of benefit)  Treatment If pregnancy is desired: Medical: Induction of ovulation Surgical: if failed induction  bilateral laparoscopic ovarian drilling (cauterization) If failed: ART Treatment If pregnancy is NOT desired: Treatment according to the main complaint Irregular cycles  Combined Oral Contraception Irregular uterine bleeding  Medical treatment  Combined Oral Contraception  Surgical treatment  D&C or hysterectomy Hirsutism  Combined Oral Contraception  Diane