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Polycystic Ovarian Syndrome

Ahmed Al-mohammed

The Objectives
1

Definition of PCOS

Development of Ovaries

Characteristic features of PCOS

4
5

Pathogenesis & developmental bases of PCOS

Hormonal abnormalities in PCOS

Definition of PCOS

Definition

Polycystic Ovarian Syndrome (PCOS) is a common

disorder affecting approximately 5-10% of
reproductive-aged women.
PCOS represents the main cause of infertility in
women and is also associated with chronic
anovulation and an excess of the hormone
androgen (hyperandrogenism).

Development of Ovaries

Development of Ovaries
Development of the ovary passes into three phases:

1st: Migration of the germ cells from the yolk sac to the
posterior body wall at level of 10th thoracic level to
enter the Genital ridge.
2nd: the germ cells differentiate into oogonia then
primary oocytes and become arrested until puberty.

Development of Ovaries
3rd: descent of the ovary to reach the pelvis along a
ligamentous cord called the gubernaculum that is
attached inferiorly to the inguinal region. The
gubernaculum persists in the adult as the ovarian
ligament and the round ligament.

Cont..
Primordial follicle
Primary follicles: unilaminar , multilaminar
Secondary follicles
Mature graafian follicle
Corpus luteum.
Corpus albican.

Characteristic features of
PCOS

Characteristic features
Two of the following three \
I. Oligo- or anovulation

II.Clinical and/or biochemical signs of

hyperandrogenism
III. Polycystic ovaries
Other causes of hyperandrogenism should be excluded
(Rotterdam Consensus definition,2003)

Pathogenesis of PCOS

Pathogenesis of PCOS
Unknown exact pathophysiological mechanism
The most widely accepted explanation is metabolic
insulin resistance lead to hyperinsulinaemia.
Evidence of decreased insulin sensitivity is seen in
both lean (30%) and obese (75%) women with
PCOS .
PCOS clusters in families genetic factors

Cont..
Hyperinsulinaemia >>
- Stimulates \ ovarian and adrenal androgen secretion
-Suppresses \ sex hormone binding globulin (SHBG)
leading to >>
increase biologically active androgens free androgens
Leading to >>
premature follicular atresia and anovulation

Elevated Insulin
Adverse effects on lipo-proteins
Causes weight gain
Makes weight loss virtually
impossible

Elevated insulin levels \

Carbohydrates converted to fat and stored in fat cells
Prevent the mobilization of fat from fat cells
Increased risk of clots

Insulin Resistance
Long-term implications
e.g. heart disease , diabetes
The effect on lipids and the cardio-vascular system results
in about a ten fold increase in the risk of heart disease
The risk of diabetes is increased to about the same extent
the pancreas just cant make that much insulin forever,
and eventually cant make enough and diabetes results.

developmental bases of PCOS

Insulin Resistance
Follicles line by theca cells and granulosa cells
Theca cells convert the cholesterol into androstenedione
Theca cells pass the androstenedione into granulosa cells
where its converted into estrone and then inte estradiol
Women with genetic susceptibility and Hyperinsulinemia
Stimulate an enzyme called cytochrome P450c 17-
in both the ovaries and the adrenal glands to produce
increased amounts of male hormones

Now , the question is ..

How and why do cysts

develop in the ovaries?

How & Why

Granulosa cells self-destruct normally after failure of
ovulation.

But >>
Theca cells dont die because they are kept alive by high
levels of insulin, preventing the follicle from collapsing,
resulting in a cyst .
Theca cells continue to produce androstenedione .
As there are no longer any granulosa cells to convert the
androstenedione into estrogens, the theca cells convert the
androstenedione into testosterone. In other words, for
whatever reason a woman may have an ovarian cyst, the
lining of the cyst will produce testosterone in most cases

Hormonal abnormalities in
PCOS

Hormonal abnormalities
LH is often higher than FSH, up to 2-3 times, as
well as high testosterone levels (> 50 ng/dl)
revealing high ovarian production.
Negative feedback on pituitary, Decreased FSH
secretions
Checking serum progesterone levels on cycle days
21-23 to confirm ovulatory function is unusually
low (< 4 ng/dl), indicating ovulatory problems

Cont..
Effects of high blood insulin levels \
1-Stimulation of adrenal male hormone production
2-Stimulation of ovarian male hormone production
3- Sensitizes follicle to respond to LH at 4 mm rather at
9.5 mm diameter
4-Inhibition of programmed death of theca cells
5-Stimulation of pituitary LH secretion

Cont..
6-Reduction of liver SHBG production
7-Stimulates the conversion of testosterone to
dihydrotestosterone, increasing hair growth & acne
8- Suppresses HDL cholesterol levels
9- Acanthosis nigricans: dark skin on neck & arm pits

Symptoms

Infertility , why ?
Absent or irregular menstrual periods , why ?
Hirsutism , why ?
Cysts on the ovaries , why ?
Acne , oily skin or dandruff , why ?
Weight gain or obesity , why ?
Male-pattern baldness or thinning hair , why ?
Pelvic pain , why ?
Anxiety or depression , why ?
Acanthosis nigricans (dark patches of skin, tan to dark
brown/black) , why ?

summary
GnRH

LH

hypothalamus

pituitary

X
ovary

androgens

Androgens block
inhibitory effect
of progesterone

This is the
time of your
questions

References
The Polycystic Ovary Syndrome - a starting point, not a diagnosis. Dr Warren Kidson MB BS,
FRACP
Polycystic Ovary Syndrome produced by the womans health program, Monash university
Polycystic Ovarian Syndrome:A common cause of irregular periods and infertility.by Serena H.
Chen, M.D.
PCOS, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PCOS, James S. Martin M.D. Southern Ontario Fertility Technologies (S.O.F.T.)

POLYCYSTIC OVARIAN SYNDROME and its association with FERTILITY , The Center for Reproduction
& Womens Health Care Robert B. McWilliams, MD

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