Year 5 Medicine

Polycystic Ovary Syndrome and Hirsutism

Stella Milsom

Overview

diagnosis of PCOS-new Rotterham Consensus

symptoms of PCOS

future health risks associated with PCOS

relevant investigation of woman with likely symptoms

management of hirsutism related to PCOS

What is polycystic ovary syndrome?

syndrome of ovarian hyperandrogenisation

associated symptoms of androgen excess

anovulation leads to menstrual irregularity

most common gynaecological condition

affecting women of childbearing age

also associated with the metabolic syndrome

POLYCYSTIC OVARIAN SYNDROMEPOLYCYSTIC OVARIAN SYNDROMEPOLYCYSTIC OVARIAN SYNDROME

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Normal ovariesvolume < 8 cm3

scattered folliclesmildly enlarged generally > 8 cm3

peripheral distribution of follicles

increased stroma

Polycystic ovariesl

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Pathogenesis of PCOS

LH insulin/IGF1 cytochrome P450

ovarian androgen production

disturbed folliculogenesis

obesity

Diagnosis of polycystic ovary syndrome

symptoms of androgen excess irregular menses acne, hirsutism

biochemical androgen excess total / free testosterone, androstenedione, LH

pelvic ultrasound 1 or both ovaries enlarged, >12 peripheral follicles

Anovulation in PCOS

presents as:absence of periodsinfrequent periods ( > 35 day

cycle)dysfunctional uterine bleedingoccasionally regular periods

risk of endometrial cancer

Biochemistry in PCOS

Raised LH or LH:FSH ratio

One or more androgen levels raisedtestosteroneandrostendioneDHEAS

Polycystic Ovaries

Normal ovaries volume < 8 cm3 scattered follicles

Polycystic OvariesGenerally >8cm3 peripheral distribution

of follicles increased stroma

2004 Consensus PCOS Definition

2 out of the following 3 features

anovulation

clinical and/or biochemical evidence of androgen excess

polycystic ovaries on ultrasound:

1 or more ovaries ≥10mls in size and ≥12 follicles

Human Reproduction, 2004

PCOS

PCOS is also associated with a characteristic metabolic syndrome that includes:

insulin resistance dyslipidemia hypertension

These features are linked with increased risks of type 2 diabetes and possibility of premature cardiovascular disease

Metabolic abnormalities in PCOS due to insulin resistance

impaired GTT 40%

Diabetes – 5x more likely than weight matched controls OGTT vs FG

gestational diabetes increased risk

dyslipidemia HDL LDL TG

potential cardiovascular risk

Associations of PCO with clinical conditions

PCO present in

75% cases of anovulatory infertility (Adams 1986, Hull 1987)

87% cases of oligomenorrhoea (Adams 1986)

80% cases of hirsutism and regular menses

(Adams 1986, Hull 1987)

83% women presenting with acne to dermatology clinic

(Bunker 1989)

30-40% women with amenorrhoea (Adams 1986)

What tests are useful?

androgens, FSH, LH, estradiol

prolactin, thyroid function, pregnancy test (causes of secondary amenorrhea)

ultrasound pelvis

What tests are useful?

remember to exclude secondary causes of PCOS

androgen secreting tumour

acromegaly

non classical CAH

Management of PCOS

symptom orientated

long term risk reduction

Management of PCOS- Current Symptoms

determine which predominates-infertility or androgen excess

then consider antiandrogen versus ovulation induction therapy

consider state of endometrium

first line medical management from diagnosis to reproduction most likely be OCP

Hirsutism and PCOS

defined as coarse terminal hair in a male distribution

do not confuse with lanugo hair

assessed by the Ferriman-Galwey score

does not always correlate with androgen levels

Management of androgen excess symptoms in PCOS

symptoms include:

hirsutism

acne

androgenic alopecia

Management of androgen excess symptoms in PCOS

First line treatment for mild hirsutism

weight loss and exercise

oral contraceptive (Estelle and Yasmin)

metformin

Effect of lifestyle in hirsute PCOS

weight gain causes an increase in insulin resistance and androgen

production in PCOS women

antiandrogen therapy is less efficacious

modest weight loss and increase in exercise e.g. 5-10% weight loss will

often improve hirsutism by reducing androgen production

OCP and hirsutism

first line treatment for hirsutes (manages endometrium and

contraception also)

synthetic E2 suppresses gonadotropin driven androgen

production

increase in SHBG decreases bioavailable T to hair follicle

addition of low dose CPA (Estelle) provides antiandrogenic

progesterone

Metformin and hirsutism

useful alternative to OCP in woman with hirsutism who also desires fertility

common to have gut side effects

commence slowly, work up to 1500mg/day

moniter with liver and renal function ( occasional hepatotoxicity, theoretical risk of

lactic acidosis)

Metformin and hirsutism

In both lean and overweight women with PCO improves insulin sensitivity and lipids

decreases hyperandrogenism

increases frequency of ovulation (40-70%) compared to placebo

Management of androgen excess symptoms in PCOS

Treatment of more severe hirsutism (refer)

OCP plus additional antiandrogen therapy: spironolactone 200mg/day cyproterone in reverse sequential regime (specialist) flutamide 250mg/day (specialist) finasteride unfunded and less effective

for the future: vaniqa cream (ornithine decarboxylase inhibitor)

Combination antiandrogen therapy

use in conjunction with OCP

specialist prescription

require monitoring (liver function)

used in more severe hirsutism or unresponsive women

course up to 36 months

require contraception

6 months before effect but may improve up to 2 years

after initiating therapy (50% reduction in FG score)

Management of PCOS-longer term

consider OCP, metformin, progestins, antiandrogens,

ovulation induction, lipid lowering agents, antihypertensives

as necessary

surveillance for diabetes, hypertension and dyslipidemia

especially if positive family history and overweight

monitor endometrium

active weight loss and exercise programme