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Amin Sabet, M.D.
04-05-2010
- Heterogenous disorder with major features including: menstrual irregularity, androgen excess, and/or polycystic ovaries.
- Most common endocrine disorder of premenopausal women. Estimated prevalence of 6-7% in general population worldwide.
- Present in up to 91% of women with euestrogenic normogonadotropic ovulatory dysfunction (Broekmans).
- Up to 35% of women with PCOS have impaired glucose tolerance and 10% have type 2 diabetes by age 40 years (Ehrmann).
- Up to 41% of adult women with type 1 diabetes have PCOS using Rotterdam criteria (see Diagnosis section below), compared with 11.9% prevalence using 1990 NIH diagnostic criteria (Codner).
- NIH criteria (1990): Exclusion of other conditions that cause menstrual irregularity and androgen excess and presence of both menstrual irregularity due to oligo- or anovulation and clinical or biochemical evidence of hyperandrogenism.
- Rotterdam criteria (2003): Exclusion of other conditions that cause menstrual irregularity and androgen excess and presence of at least two of the following: 1) oligoovulation or anovulation; 2) clinical and/or biochemical evidence of hyperandrogenism; 3) polycystic ovaries by ultrasound (> 11 follicles measuring 2-9 mm in each ovary).
- Conditions to be excluded for diagnosis of PCOS: pregnancy, congenital adrenal hyperplasia (CAH), androgen-secreting tumors, hypothyroidism, hyperprolactinemia, Cushing's syndrome.
- Lab tests: serum HCG, prolactin, TSH, LH, FSH, free testosterone, DHEA-S, 17-OH progesterone, 1 mg overnight dexamethasone suppression test (if symptoms/signs of Cushing's present).
- In PCOS, LH to FSH ratio often elevated. Androgrens including free testosterone and DHEA-S usually high.
- Non-classic CAH is suggested by elevated AM serum 17-OH progesterone in early follicular phase and confirmed by measurement of 17-OH progesterone after ACTH stimulation.
- Women with androgen-secreting tumors typically present with amenorrhea, progressive hirsutism, virilization (deepening voice, clitoromegaly), free testosterone > 150 mg/dL or DHEA-S > 800 mcg/dL, and low LH.
- Pelvic ultrasound not needed for NIH criteria.
- Consider screening for impaired glucose states including fasting blood glucose and/or oral glucose tolerance test.
- Menstrual irregularity characterized by oligomenorrhea (link to menstrual cycle and glycemia) or amenorrhea with typical onset in peripubertal period (primary amenorrhea) or after weight gain (secondary amenorrhea).
- Anovulatory infertility is frequently seen.
- Hyperandrogenism characterized by hirsutism (excessive terminal body hair in male pattern), acne, and/or male pattern hair loss.
- Chronic anovulation can lead to endometrial hyperplasia, dysfunctional uterine bleeding, and possibly endometrial cancer.
- Can occur in normal weight individuals.
- Weight loss often improves hyperandrogenism, menstrual irregularity, and infertility.
- Hirsutism generally managed with estrogen-progestin contraceptive (OCP) medication (usually containing ethinyl estradiol in a dose of 20 to 35 mcg/day and a non-androgenic progestin such as norgestimate, desogestrel, or drospirenone).
- Spironolactone (starting dose of 50mg once or twice daily, can be increased to 100mg twice daily) has additional benefit in hirsutism but should not be used without contraception since maternal spironolactone use may prevent normal sex characteristics in the developing male fetus.
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Metformin therapy can be used to manage metabolic derangements associated with PCOS (obesity, insulin resistance), may decrease androgen levels and improve menstrual irregularity.
- Endometrial protection may be accomplished via estrogen-progestin OCP or intermittent progestin therapy such as medroxyprogesterone acetate 10mg daily for 7-10 days every 1-2 months.
- Clomiphene citrate is first line drug therapy for induction of ovulation in women with PCOS, although metformin may also be effective.
- Hyperglycemia in people with PCOS and diabetes is managed no differently than in others with diabetes.
- Surveillance for and treatment of prevalent co-morbid conditions: obesity, insulin resistance, type 2 diabetes, dyslipidemia (typically high triglycerides and LDL, low HDL), fatty liver, and sleep apnea.
- Given that ultrasonographic criteria of polycystic ovaries may be difficult to document and that otherwise normal women may have polycystic ovaries, we continue to use the 1990 NIH criteria to make the diagnosis of PCOS.
- Women with typical features of PCOS (onset of menstrual irregularity in peripubertal period, overweight/obesity) and mild hirsutism may not require measurement of serum androgens, whereas those with moderate to severe or progressive hirsutism, any virilization, or onset of menstrual irregularity after age 20 should be tested for testosterone and DHEA-S excess to evaluate for androgen-secreting tumor.
- In overweight or obese women with PCOS, we typically consider metformin as a first line therapy given its favorable metabolic effects and potential efficacy as an agent to lower androgen levels and correct menstrual irregularity.
- Based on limited available data (Cheung), we consider referral for endometrial biopsy in women with PCOS and a history of fewer than five menstrual periods yearly.
- American Association of Clinical Endocrinologists Polycystic Ovary Syndrome Writing Committee;
American Association of Clinical Endocrinologists Position Statement on Metabolic and Cardiovascular Consequences of Polycystic Ovary Syndrome.;
Endocr Pract;
2005; Vol.
11; pp.
126-34;
ISSN:
1530-891X;
PUBMED: 15915567
Rating:
Basis for recommendation
Comments:American Association of Clinical Endocrinologists position statement regarding metabolic aspects of PCOS.
- Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group;
Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).;
Hum Reprod;
2004; Vol.
19; pp.
41-7;
ISSN:
0268-1161;
PUBMED: 14688154
Rating:
Basis for recommendation
Comments:2003 Rotterdam consensus on PCOS diagnostic criteria.
- Zawadski, JK, Dunaif, A. ;
Diagnostic criteria for polycystic ovary syndrome: Towards a rational approach. ;
Polycystic Ovary Syndrome. Dunaif, A, Givens, JR, Haseltine, FP, Merriam, GE (Eds). Oxford, UK: Blackwell. ;
1992 ; Vol.
59-69 ;
Rating:
Basis for recommendation
Comments:NIH diagnostic criteria for PCOS.
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