Dryan Ariapratita

Preseptor:
Dr. H. Dadan Sudandi Sp.OG

Polycystic Ovarian
Syndrome

Practice Essential
Women with polycystic ovarian syndrome
(PCOS) have abnormalities in the
metabolism of androgens and estrogen and
in the control of androgen production.
PCOS can result from abnormal function of
the hypothalamic-pituitary-ovarian (HPO)
axis.
A woman is diagnosed with polycystic
ovaries (as opposed to PCOS) if she has 12
or more follicles in at least 1 ovary

Essential update: AACE/ACE and AES

Society release new guidelines
In November 2015, the American
Association of Clinical Endocrinologists
(AACE), American College of
Endocrinology (ACE), and Androgen
Excess and PCOS Society (AES) released
new guidelines in the evaluation and
treatment of PCOS.

Essential update: AACE/ACE and AES

Society release new guidelines
The diagnostic criteria for PCOS should
include two of the following three
criteria:
chronic anovulation
hyperandrogenism (clinical/biologic)
polycystic ovaries

In addition to clinical findings:

obtain levels of serum 17hydroxyprogesterone and anti-Mllerian
hormone to aid the diagnosis of PCOS.

Essential update: AACE/ACE and AES

Society release new guidelines
Free testosterone levels sensitive for
determining androgen excess,obtained
with equilibrium dialysis techniques
Women with PCOS should also be
evaluated and/or treated for :
Reproductive function
Hirsutism
Alopecia
Acne

Sign and Symptoms

Diagnosis
On examination, findings in women with
PCOS may include the following:
Virilizing signs
Acanthosis nigricans
Hypertension
Enlarged ovaries: May or may not be
present; evaluate for an ovarian mass

Diagnosis
Testing Exclude all other disorders that
can result in menstrual irregularity and
hyperandrogenism, including

Adrenal or ovarian tumors

Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinemia
Acromegaly
Cushing syndrome

Diagnosis
Baseline screening laboratory studies for
women suspected of having PCOS include
the following:

Thyroid function tests (eg, TSH, free thyroxine)

Serum prolactin level
Total and free testosterone levels
Free androgen index
Serum hCG level
Cosyntropin stimulation test
Serum 17-hydroxyprogesterone (17-OHPG) level
Urinary free cortisol (UFC) and creatinine levels
Low-dose dexamethasone suppression test
Serum insulinlike growth factor (IGF)1 level

Diagnosis
Other tests used in the evaluation of PCOS
include the following:

Androstenedione level
FSH and LH levels
GnRH stimulation testing
Glucose level
Insulin level
Lipid panel

Diagnosis
Imaging tests The following imaging
studies may be used in the evaluation of
PCOS:
Ovarian ultrasonography, preferably using
transvaginal approach
Pelvic CT scan or MRI to visualize the adrenals
and ovaries

Diagnosis
Procedures An ovarian biopsy may be
performed for histologic confirmation of
PCOS; however, ultrasonographic
diagnosis of PCOS has generally
superseded histopathologic diagnosis.
Endometrial biopsy may be obtained to
evaluate for endometrial disease, such
as malignancy.

Management
Lifestyle modifications are considered
first-line treatment for women with
PCOS. Such changes include the
following :
Diet
Exercise
Weight loss

Pharmacotherapy
Pharmacologic treatments are reserved
for so-called metabolic derangements,
such as
anovulation
hirsutism
menstrual irregularities.

First-line medical therapy usually

consists of an oral contraceptive to
induce regular menses.

Pharmacotherapy
Medications used in the management of PCOS
include the following:
Oral contraceptive agents (eg, ethinyl estradiol,
medroxyprogesterone)
Antiandrogens (eg, spironolactone, leuprolide, finasteride)
Hypoglycemic agents (eg, metformin, insulin)
Selective estrogen receptor modulators (eg, clomiphene
citrate)
Topical hair-removal agents (eg, eflornithine)
Topical acne agents (eg, benzoyl peroxide, tretinoin
topical cream (0.020.1%)/gel (0.010.1%)/solution
(0.05%), adapalene topical cream (0.1%)/gel (0.1%,
0.3%)/solution (0.1%), erythromycin topical 2%,
clindamycin topical 1%, sodium sulfacetamide topical
10%)

Surgery
Surgical management of PCOS is aimed
mainly at restoring ovulation. Various
laparoscopic methods include the following:
Electrocautery
Laser drilling
Multiple biopsy

Definition
Polycystic ovarian syndrome, or
PCOS, is a condition in which a woman's
levels of the sex hormones estrogen and
progesterone are out of balance. This
leads to the growth of ovarian cysts
(benign masses on the ovaries)

Definition

Epidemiology

Etiology
High serum concentrations of androgenic hormones :
testosterone
androstenedione
dehydroepiandrosterone sulfate (DHEA-S)

PCOS is also associated with :

peripheral insulin reistance
hyperinsulinemia
obesity amplifies the degree of both abnormalities.

A proposed mechanism for anovulation and elevated

androgen levels :
LH increased, Ovarian theca cell increased
Androgen ( testosteron , androstenedione ) increased
FSH decreased, Estrogen decreased,

Etiology

Prognosis
Evidence suggest that women with polycystic
ovarian syndrome (PCOS) may be at increased
risk for cardiovascular and cerebrovascular
disease.
Approximately 40% of patients with PCOS have
insulin resistance that is independent of body
weight . Increaased risk for type 2 diabetes
mellitus.
Patients with PCOS are also at an increased risk
for endometrial hyperplasia and carcinoma.

History
The history of patients with polycystic
ovarian syndrome (PCOS) may include
the following:

Menstrual disorders
Adrenal enzyme deficiencies
Hirsutism
Infertility
Obesity and metabolic syndrome
Diabetes

Pathophysiology

Manifest Clinis
Menstrual abnormalities
chronic anovulation.
oligomenorrhea (ie, menstrual bleeding that occurs at
intervals of 35 days to 6 months, with < 9 menstrual
periods per year)
secondary amenorrhea (an absence of menstruation for 6
months).
Dysfunctional uterine bleeding and infertility are the
other consequences of anovulatory menstrual cycles.
The menstrual irregularities in PCOS usually present
around the time of menarche

Manifest Clinis
Hyperandrogenism
excess terminal body hair in a male
distribution pattern.
acne and/or male-pattern hair loss
(androgenic alopecia).
increased muscle mass, voice deepening)
ferriman-gallwey (mFG) score

Manifest Clinis
Infertility
Ovulate intermittenly
Conception may take longer than in other
women
Have fewer children than they had planned
Rate of miscarriage is also higher in affected
women.

Manifest Clinis

Manifest Clinis
Obesity and metabolic syndrome
half of all women with PCOS are clinically
obese.
have characteristics of metabolic syndrome;
atherosclerosis.
cardiovascular risk in PCOS results in the
higher cardiovascular-event rates.

Manifest Clinis
Diabetes mellitus
ACOG recommends screening for type 2
diabetes
impaired glucose tolerance in women with
PCOS by obtaining a fasting glucose level and
then a 2-hour glucose level after a 75-g
glucose load.
10% of women with PCOS have type 2
diabetes mellitus
30-40% of women with PCOS have impaired
glucose tolerance by 40 years of age.

Manifest Clinis

Physical Examination
Hirsutism and virilizing signs
ferriman-gallwey (mFG) score

Obesity
waist circumference >88cm

Acanthosis nigricans
Hiperpigmentation of the skin according to
the score

Blood pressure
130/80mmHg or higher

Enlarged ovaries
May not always be present

Diagnostic Considerations
Although no agreed-upon diagnostic criteria
currently exist for adolescentpolycystic ovarian
syndrome (PCOS), hyperandrogenemia is
essential for the diagnosis in this age group.
All conditions that mimic PCOS should be ruled
out before a diagnosis of PCOS is confirmed.

Diagnostic Considerations
Consider the following in the differential diagnosis of
PCOS:

Ovarian hyperthecosis
Congenital adrenal hyperplasia (late-onset)
Drugs (eg, danazol, androgenic progestins)
Hypothyroidism
Patients with menstrual disturbances and signs of
hyperandrogenism
Idiopathic hirsutism
Familial hirsutism
Masculinizing tumors of the adrenal gland or ovary (rapid onset
of signs of virilization)
Cushing syndrome (low K+, striae, central obesity, high cortisol;
high androgens in adrenal carcinoma)
Hyperprolactinemia
Exogenous anabolic steroid use
Stromal hyperthecosis (valproic acid)

Differential Diagnoses
3-Beta-Hydroxysteroid Dehydrogenase
Deficiency
Acromegaly
Adrenal Carcinoma Imaging
Amenorrhea
Congenital Adrenal Hyperplasia
Gigantism and Acromegaly
Hyperprolactinemia
Hyperthyroidism
Hypothyroidism
Iatrogenic Cushing Syndrome
Ovarian Tumors

Approach Considerations
Biochemical and/or imaging studies must be done
to rule out these other possible disorders and
ascertain the diagnosis.
The Royal College of Obstetricians and
Gynaecologists (RCOG) recommends the following
baseline screening tests
thyroid function tests,
serum prolactin levels,
free androgen index

A serum human chorionic gonadotropin (hCG)

level should be checked to rule out pregnancy in
women with oligomenorrhea or amenorrhea.

Screening Laboratory
Studies
Late-onset congenital adrenal hyperplasia due to
21-hydroxylase deficiency can be ruled out by
measuring serum 17-hydroxyprogesterone levels
after a cosyntropin stimulation test
A 17-hydroxyprogesterone level of less than
1000 ng/dLmeasured 60 minutes after
cosyntropin stimulationrules out late-onset
congenital adrenal hyperplasia.
Women with PCOS should be screened for
Cushing syndrome or acromegaly only if there is
a clinical suspicion of these conditions.

Hormone Levels

Imaging for PCOS

USG
By transvaginal approach
Perform ovarian morphology
USG if pelvic exam
inadequate,abdomnial pain, high
testosterone
Its needed to support diagnositc
patient with amenorrheic

CT scan and MRI

If a tumor is suspected
To visualize adrenals and ovaries
Those patient whom TVUS is
inappropriate (adolescent girls.)

Longitudinal transabdominal ultrasonogram of an ovary.

This image reveals multiple peripheral follicles

Histologic Findings

Low power, H and E of an ovary containing multiple cystic

follicles in a patient with PCOS.

Approach Considerations

Certain lifestyle changes,

such as diet and exercise, are considered first-line treatment for
adolescent girls and women with polycystic ovarian syndrome
(PCOS).

Metabolic derangements, such as anovulation, hirsutism,

and menstrual irregularities.
oral contraceptives, metformin, prednisone, leuprolide, clomiphene,
and spironolactone.

Mean platelet volume (MPV)

ethinyl estradiol/cyproterone acetate or metformin for the treatment of
women with PCOS seemed to have similar beneficial effects in
reducing MPV

Consultation with an endocrinologist is necessary

Lifestyle Modifications

The American College of Obstetricians and

Gynecologists (ACOG) and the Society of Obstetricians
and Gynaecologists of Canada (SOGC)

indicate that lifestyle modifications such as weight loss

and increased exercise in conjunction with a change in
diet consistently reduce the risk of diabetes.

Drug Treatment

Anovulation

The American College of Obstetricians and

Gynecologists (ACOG) and Society of Obstetricians and
Gynaecologists of Canada (SOGC) recommend
clomiphene citrate as first-line therapy to stimulate
ovulation when fertility is desired

Hirsutism
A clear primary treatment for
hirsutism in women with
polycystic ovarian syndrome
(PCOS) remains lacking.
short-term, nonpharmacologic
treatments of hirsutism include
shaving and the use of chemical
depilatories and/or bleaching
cream.
Long-term, more permanent
measures for unwanted hairs
include electrolysis and laser
treatment.

Medication Summary

Thank you..