Polycystic Ovarian Syndrome (PCOS) is a rather common presentation in the primary care setting and the patients usually visit their primary care doctor initially before consulting a gynaecologist. The initial workup and diagnosis can certainly be carried out by the physician before referring to a gynaecologist.
Polycystic Ovarian Syndrome(PCOS) Usual Presenting features
The diagnosis is important as besides the gynaecological problems they are more liable to develop obesity and infertility. Apart from the above Polycystic Ovarian Syndrome (PCOS) is also associated with other medical conditions like
- Insulin resistance and high incidence of gestational diabetes mellitus and type II diabetes mellitus (I I% of obese Polycystic Ovarian Syndrome (PCOS) patients have abnormal glucose tolerance).
- Dyslipidaemia with increased risk of cardiovascular disease
- Increased incidence of endometrial carcinoma
- Examination usually does not reveal anything specific but increased skin pigmentation may be present (acanthosis nigricans).
Investigations Polycystic Ovarian Syndrome (PCOS)
- LH is characteristically raised.
- FSH is normal.
- Testosterone level is slightly raised.
- T3, T4, TSH, prolactin – normal.
- Ultrasound examination reveals polycystic ovaries.
- Ovarian and androgen-secreting adrenal tumours (very high level of testosterone).
- Cushing syndrome
- Congenital adrenal hyperplasia.
The last two conditions have characteristic clinical and biochemical features.
Management Polycystic Ovarian Syndrome (PCOS)
Management is mainly directed to a reduction of obesity, treatment of hirsutism with antiandrogen therapy as well as treatment of oligomenorrhoea with attendant infertility and correction of other hormonal and biochemical parameters. It has been shown that even 10% reduction of weight would improve ovarian function with the better result from ovarian stimulation therapy; it also reduces the risk of development of diabetes mellitus.
Medical treatment of hirsutism and acne:
Hirsutism is due to hyperandrogenism which could be treated with
- Cyproterone acetate (antiandrogen)- The two preparations can be used in combined shows the good result, Dianette (ethinyl estradiol + cyproterone acetate) [BNF].
- Spironolactone and finasteride- these two may be used as antiandrogens alternatively. Finasteride can theoretically cause feminization of a male fetus so appropriate contraceptive precautions should be taken.
- Isotretinoin, topical medications and antibiotics may be used for acne.
- Cosmetic treatment with depilatory creams or electrolysis may be helpful.
Treatment of infertility
This will fall in the domain of the gynaecologist. Following methods are available
- Drugs: Cyclic use of clomiphene has been used for this purpose with an approximately 50% success rate. Multiple pregnancies and ovarian hyperstimulation syndrome are the complications (characterized by cystic ovarian enlargement, extravascular fluid accumulation and intravascular volume depletion. This is a life-threatening condition needing critical care input).
- Ovarian surgery: Traditionally wedge resection of ovaries was the treatment of choice. Newer methods of laparoscopic drilling of ovaries by diathermy are being evaluated.
Newer drugs in Polycystic Ovarian Syndrome (PCOS)
Since insulin resistance is the key to many of the metabolic and hormonal problems in Polycystic Ovarian Syndrome (PCOS), metformin (500-1500 mg) is increasingly being used in PCOS even in non-diabetic patients. This will help in the decrease in weight, correction of metabolic and hormonal imbalance and even help in ovulation. Studies are ongoing to find out its exact role in PCOS.
Causes of Hirsutism
- Ovarian- PCOS, Hyperthecosis, Ovarian tumours
- Adrenal- Congenital adrenal hyperplasia, Adrenal tumours, Cushing syndrome
- Idiopathic- With elevated testosterone, With normal testosterone
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