Reproductive System & Sexual Health >
Polycystic Ovary Syndrome (PCOS)

“A condition characterised by multiple small cysts (underdeveloped follicles that are unable to stimulate ovum maturation) within the ovary and excess androgen (i.e. testosterone) production. PCOS is the most common cause of hirsutism”

Risk Factors
  • Obesity and metabolic syndrome
  • Family history of PCOS or T2DM
  • Lack of exercise
  • Age between 15-30
Aetiology
  • Exact aetiology unknown – genetic component
Pathophysiology
  • Hypersecretion of LH and hyposecretion of FSH from the pituitary gland affect the ovaries and adipose tissue in a perpetuating cycle
  • Ovaries:
    • Impaired follicular development in ovaries
    • Chronic anovulation
    • Hyperandrogenism
      • Further worsens insulin resistance and hyperinsulinaemia → obesity
      • Increases extra-glandular aromatisation → further pituitary dysfunction
  • Adipose tissue:
    • Obesity
    • Hyperinsulinaemia
    • Insulin resistance
    • Extra-glandular aromatisation → perpetuates pituitary dysfunction
Clinical Presentation
  • Amenorrhoea/ oligomenorrhoea
  • Hirsutism
  • Acne following menarche
  • Patients are frequently obese
  • Evidence of insulin resistance
  • Infertility due to irregular/ absent ovulation
  • Alopecia
Investigations
  • Ovarian ultrasound – thickened capsule, multiple 3-5mm cysts, hyperechogenic stroma
  • Elevated levels of
    • Serum total testosterone/ free androgen index
    • 17a-hydroxyprogesterone
    • LH and oestrogen
    • Serum prolactin
Management
  • Local therapy for hirsutism
    • Shaving
    • Waxing
    • Depilatory or bleaching creams
    • Eflornithine cream (antiprotozoal) inhibits ornithine decarboxylase → hair growth in a minority of cases
  • Systemic therapy for hirsutism
    • Oestrogens (e.g. COCP) – suppress ovarian androgen production
    • Cyproterone acetate 50-100mg/day – anti- androgens; progestogen; teratogen; glucocorticoid (weak)
    • Spironolactone 200mg/day
    • Finasteride 5mg/day – 5a-reductase inhibitor that prevents formation of dihydrotestosterone in the skin
  • Therapy for other symptoms
    • Cyclical oestrogen/progesterone to treat amenorrhoea/ oligomenorrhoea
    • Metformin for insulin resistance – may also improve ovulation
    • Clomifene 50-100mg/day on day 2-6 of the menstrual cycle achieves ovulation in 75% women with PCOS
    • Low-dose FSH given to those who do not respond to clomifene
Complications
  • Insulin resistance
  • T2DM
  • Hypertriglyceridemia
  • Hypercholesterolaemia
  • Cardiovascular disease
  • Stroke
  • Sleep apnoea (due to obesity)
  • Endometrial cancer

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