Polycystic ovarian syndrome (PCOS) is a common endocrine disorder affecting between 4% and 8% of reproductive aged women. About 20% of couples seeking fertility treatment do so due to anovulation and 85%-90% of those have PCOS. Usually these patients do not ovulate and pregnancy does not occur. The symptoms and signs of PCOS are very heterogenous and presents with menstrual irregularities like oligomenorrhoea or amenorrhoea, hirsutism, acne, alopecia and a characteristic appearance of the ovaries on ultrasound examination.  Due to abnormal follicular development, the ovaries have multiple small follicles usually measuring <5mm dispersed around the periphery of the ovary in a pattern often referred to as a "string of pearls".

This ultrasound appearance alone does not mean the patient has polycystic ovarian syndrome. Other clinical findings which comprise the syndrome include:

  • Polycystic appearing ovaries
  • Hyperandrogenism . Increased:
    • testosterone
    • DHEAS - dehydroepiandrostenendione sulfate (adrenal gland)
  • Hirsutism (male pattern hair growth such as facial hair)
  • Hyperinsulinemia (increased insulin secretion) and Insulin Resistance
  • Abnormal uterine bleeding oligo-ovulation (irregular ovulation)
  • Amenorrhea (absence of uterine bleeding)
  • Infertility
  • Obesity. Not clear if this is a cause or an effect. Not all patients with PCOS are overweight.
  • Laboratory findings Elevated LH Reversal of the LH/FSH ratio as LH becomes higher than FSH throughout the menstrual cycle
  • Other hormone elevations:
    • Estrogens
    • 17-OHP - 17 hydroxyprogesterone
  • Skin abnormalities Acanthosis Nigricans (darkened scaly like rash commonly on patients neck)
  • Skin tags - small outgrowths of skin
  • Possible long term effects Increased risk of cardiovascular disease from increased lipids
  • Increased risk of endometrial cancer
  • Increased risk of breast abnormalities
  • Increased risk of developing type II diabetes mellitus
  • Increased risk of heart disease

Infertility:

PCOS is associated with infertility. The most likely cause of infertility is anovulation or lack of ovulation. Ovulation can be induced by gonadotropins or by correction of insulin resistance. Some investigators have reported a lower than normal fertilization rate during IVF in women with PCOS. There may also be a higher miscarriage rate in women with PCOS also, but this has been debated. Women with PCOS are at increased risk of ovarian hyperstimulation when taking gonadotropins. A history of PCOS and/or irregular menses should be reported to physician before taking any fertility medications.

Diagnosis:

Diagnosis can be made by history of irregular menses, physical examination ( obesity, hirsutism, acne, acanthosis niagricans) laboratory investigation ( raised LH) and polycystic ovaries on ultrasound ( necklace appearance of cysts, which arranged at periphery of the ovary).



 

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