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POLYCYSTIC OVARIAN SYNDROME (PCOS) OR DISEASE (PCOD)

PATHOGENESIS:

Multiple follicles do not develop and mature properly so they do not ovulate.
LH to FSH ratio is often higher.
Increased level of male hormones testosterone and Andronestedione.
- Because of increase in LH level or an increase in insulin level in the blood.
Adipose tissue possesses aromatase enzyme that converts androstenedione to estrone and testosterone to estradiol.
Excess of adipose tissues in PCOS
- Excess androgen → Hirsutism and virilization
- Estrogens→ Inhibits FSH via negative feedback.
Insulin resistance is present in obese and nonobese women with PCOS.
- High responsiveness to insulin by the ovary as opposed to resistance of the whole body.
- Insulin has a direct stimulatory effect on androgen secretion by the ovary.
- Hyperinsulinemia increases
  - GnRH pulse frequency
  - LH over FSH dominance
  - Increased ovarian androgen production
  - Decreased follicular maturation

CLINICAL FEATURES:

Patient age – 15 – 25 years.

Chief Complaints :

Oligomenorrhea / amenorrhea / DUB
Infertility (30 % cases)
Hirsutism

Ovarian Pathology :

Ovaries are bilaterally enlarged
Colour – Pearly white
Capsule – Tunica Albuginea is thickened
Theca cell hypertrophy (Stromal hyperthecosis due to T androgen levels)
Multiple follicular cysts, localized along the surface of ovary giving a “necklace appearance” on USG.

Signs and symptoms :

Hyperandrogenism (acne, hirsutism, Androgenic alopecia not virilization)
Menstrual disturbance
Infertility
Abnormal glucose tolerance test
Obesity (BMI > 30 kg/m2and waist :Hip ratio > 0.88, waist line > 3)

Possible late sequale:

Diabetes mellitus
Dyslipedemia
Hypertension, cardiovascular disease
Endometrial cancer
Ovarian Carcinoma
Adrenal hyperplasia
Breast cancer

Others :

HAIR-AN syndrome i.e. Hyper Androgenism, Insulin resistance and Acanthosis nigricans is seen in patients of PCOS.
Acanthosis nigricans

Thickened and pigmented skin

Commonly affected areas – Nape of neck, Inner thighs and Axilla.

The skin changes are due to insulin resistance.

DIAGNOSIS:

Hormonal changes in PCOS
Hormones Increased	Hormones Decreased
Androgens (Testosterone, Androstenedione DHEAS) Luteinizing hormone (LH > 10 IUI ml) Estrogen Insulin (> 10 m IU / L) Prolactin (in some patients) LDL / cholesterol and triglycerides	Follicle stimulating hormone (FSH) Progesterone (due to anovulation) Sex hormone binding Globulin. HDL & Apoprotein A-I

Ratio of LH/FSH in PCOS is > 2:1

USG – Sonographic criteria for PCOD includes :

> 12 small cysto (2 to 9 mm in diameter)
Increased ovarian volume (> 10 ml) or both
The amount of stroma is increased relative to the number of follicles.

MANAGEMENT:

Symptom oriented
Due to Central role of insulin resistance to the aetiology of PCOS, treatment is now aimed towards
- Improve insulin resistance → Improves the regularity of menstrual cycles, ovulation, androgen levels.
- Life style modification and metformin
Continuous administration of GnRH analogues can be used in PCOD.

The life style modifications recommended in PCOS :

Dietary modification
Moderate exercise
Cessation of smoking
Moderate alcohol and caffeine intake

Metformin

Improves menstrual cyclicity and ovulation in PCOS
Offered to all women with anovulatory infertility due to PCOS
Metformin is used as stand alone first line therapy it is continued for 6-12 months if regular ovulation is documented
If it has not been effective after 3-6 months clomiphene should be added for further 6 months.

Surgery :

Indications :

Failure of medical therapy.
In case of Hyperstimulation.
Use of GnRH analogues is a cost constraint.

Procedure of Choice :

Endoscopic cauterization or CO2 laser vapourisation of the cysts.
Laparoscopic ovarian drilling restores ovulation in PCOS patients resistant to clomiphene

Exam Important

Elevated LH hormone is seen in PCOD
PCOD Can cause infertility
PCOD May be associated with abnormal glucose tolerance test
Polycystic ovaries is characterized by obesity,Theca cell hyperplasia and Hyperandrogenism both,Amenorrhoea or Oligomenorrhea, infertility and hirsutism/Alopecia
Increased LH / FSH ratio & DHEAs are seen in PCOD
Polycystic ovary disease is the most common cause of Hirsutism
Poly cystic ovarian disease is associated with Endometrial carcinoma
High LH, low FSH and low Estradiol are the hormonal changes seen in PCOD
Positive progesterone challenge test in a patient of secondary amenorrhoea, seen in PCOD
Sample for testing LH and FSH are best taken on 8-10 days of menstrual cycle in suspected case of PCOS
Ovarian carcinoma, Endometrial carcinoma,Adrenal hyperplasia & Insulin Resistance are associated with PCOD
GnRH analogue is used in treating PCOD
Metformin is used in treatment & control of Diabetes & PCOD

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POLYCYSTIC OVARIAN SYNDROME (PCOS) OR DISEASE (PCOD)