diagnosis & management...most patients with pcos have ovulatory dysfunction which is manifested...

Diagnosis & management

by: Abeer Hussein

Rotterdam criteria ( 2003)

The criteria require two out of three of the following to make a diagnosis

(after ruling out CAD, androgen-secreting tumors &cushing syndrome: )

1) ovulatory dysfunction(oligo/anovulation)

2) Evidence of hyperandrogenism

3 polycystic ovaries on US.

1 . Ovulatory dysfunction . Most patients with PCOS have ovulatory dysfunction which is manifested as

menstrual irregularities, such as oligomenorrhea (fewer than normal menses)

or amenorrhea (no menses.)

A total of 60% to 85% of patients with PCOS and oligo-ovulation will have

oligomenorrhea,

but the remainder may seemingly have normal menses. Therefore, presence

of ovulation can be verified through alternative means, such as checking for

an elevated progesterone level in the luteal phase of the cycle.

As a result of irregular ovulation, these women lack adequate progesterone

and experience chronic estrogen exposure to the endometrium. This can

result in breakthrough or irregular uterine bleeding and can put these

patients at increased risk for endometrial hyperplasia and cancer.

So, in patients who have had prolonged anovulation without treatment or

have had a history of oligomenorrhea, an endometrial biopsy is indicated in

order to rule out endometrial hyperplasia and/or cancer.

2) Evidence of hyperandrogenism :

a)Clinical hyperandrogenism.

b)Biochemical hyperandrogenism

a)Clinical hyperandrogenism.

Women with PCOS may exhibit hirsutism, acne, or male pattern hair loss

(alopecia.)

1

b)Biochemical hyperandrogenism

Typically, testosterone and free testosterone are measured and are usually in

the upper range of normal or slightly above the normal range for women.

Dehydroepiandrosterone sulfate (DHEAS) is a marker of adrenal androgen

production, and is slightly elevated in women with PCOS. DHEAS levels greater

than 700 ng/dL suggest an adrenal tumor, but this is very rare.

3) polycystic ovaries on US:

US criteria for diagnosis:

1) Presence of at least 10_12 follicles in one ovary measuring <10mm in

diameter.

AND/OR

2) Increased ovarian volume>10mm in one or both ovaries.

Transvaginal ultrasound

showing characteristic

polycystic appearance of the

ovary. Multiple small dark circles

line the periphery of the ovary.

Transvaginal ultrasound is more sensitive than a transabdominal approach,

particularly in obese patients, but may not be appropriate to perform in a

young female.

ALTHOUGH US is a major diagnostic tool, it’s not the only one, because not all

females with PSOS have poly cystic ovaries on US and not all females with

ovarian cysts have PSOS.

Management of PCOS:

1) Weight loss

is the most effective method in restoring normal ovulation and

menstruation.

Weight reduction results in improvement in all symptoms of obese women

with PCOS.

Aim of treatment: -decrease insulin. -treatment of hirsutism or acne. -restoration of regular menstruation . -prevention of endometrial hyperplasia or cancer . -restoration of fertility.

2) hypoglycemic agents (metformin:)

it decrease insulin resistance, helps in losing weight and enhances ovulation.

Aim of treatment: -decrease insulin resistant. -treatment of hirsutism or acne. -restoration of regular menstruation . -prevention of endometrial hyperplasia or cancer . -restoration of fertility.

3) progestins or OCPs:

regulate the periods, induce ovulation and some androgenic effect,

minimizes endometrial hyperplasia or cancer.


4) Antiandrogens work to suppress hirsutism by competitive inhibition

at the level of the testosterone receptor.

a. Spironolactone (25 to 100 mg twice daily): aldosterone antagonist; and the

clinical effect may take several months and may induce hyperkalemia

b. Flutamide (125 to 250 mg/d): androgen-receptor agonist; rare association

with hepatotoxicity

c. Finasteride (5 mg/d): 5 -reductase inhibitor

d. Cyproterone acetate: not available

in the USA


5) Treatment of infertility:

Clomiphene citrate, induces ovulation.

*for patients who are not responding to clomiphene, diet, or lifestyle

modification, there are other options: assisted reproductive

technology(ART),IVF etc. Aim of treatment: -decrease insulin. -treatment of hirsutism or acne. -restoration of regular menstruation . -prevention of endometrial hyperplasia or cancer .

-restoration of fertility.

diagnosis & management...most patients with pcos have ovulatory dysfunction which is manifested...

Documents