Year 5 Medicine Stella Milsom Polycystic Ovary Syndrome and Hirsutism

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
POLYCYSTIC OVARIAN
OVARIAN SYNDROME
SYNDROME


Normal ovaries
Polycystic ovaries
 volume < 8 cm3
 mildly enlarged
 scattered follicles  generally > 8 cm3
 peripheral distribution
of follicles

increased stroma
Pathogenesis of PCOS
LH
 insulin/IGF1

obesity
 cytochrome P450


 ovarian androgen production

disturbed folliculogenesis
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 periods
infrequent periods ( > 35 day cycle)
dysfunctional uterine bleeding
occasionally regular periods
risk of endometrial cancer
Biochemistry in PCOS
Raised LH or LH:FSH ratio
One or more androgen levels raised
testosterone
androstendione
DHEAS
Polycystic Ovaries
Normal ovaries
 volume < 8 cm3
 scattered follicles
Polycystic Ovaries
Generally >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