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Polycystic Ovarian Syndrome

Topic updated on 02/13/17 9:17am

Snapshot
  • A 31-year-old G0 woman presents with difficulty becoming pregnant. She reports trying to conceive a child for over a year; however, she has not been successful. Past medical history is significant for type 2 diabetes mellitus and obesity. On physical exam, there is acne and hair on the upper lip and chin. There is also acanthosis nigricans in the posterior neck. Blood tests reveal an elevated free testosterone level and LH:FSH of 3.
Introduction
  • Endocrinopathy that can result in
    • ovarian dysfunction
      • can lead to primary or secondary amenorrhea and oligomenorrhea
        • prevents formation of the corpus luteum, impairing progesterone synthesis which leads to
          • unapposed estrogen proliferative effect on the endometrium that results in
            • bleeding
            • increased risk of endometrial hyperplasia and cancer 
    • hyperandrogenism
      • may present as acne and hirsutism
    • polycystic ovaries
  • Pathogenesis
    • mechanism is unclear
      • peripheral insulin resistance leads to hyperinsulinemia
      • ovarian stimulation leading to excess androgen production
  • Epidemiology
    • a common cause of infertility in woman of reproductive age
    • obesity is a risk factor
Presentation
  • Symptoms
    • menstrual dysfunction
      • e.g., dysfunctional uterine bleeding and amenorrhea
    • infertility
    • hirsutism
    • acne
  • Physical exam
    • obesity
    • hirsutism
    • acne
    • acanthosis nigricans 
    • bilateral enlarged ovaries on pelvic exam
Evaluation
  • Laboratory testing
    • total and free testosterone level
    • LH/FSH > 3
  • Pelvic ultrasound
    • polycystic ovaries
Differential
  • Cushing syndrome
  • Non-classical congenital adrenal hyperplasia
  • Androgen-secreting tumor
  • Pregnancy
  • Premature ovarian failure
  • Thyroid disease
    • hyper- or hypothyroidism
  • Prolactinoma
Treatment
  • Medical therapy
    • obesity
      • life-style modification
        • diet and exercise
    • anovulation
      • hormonal contraceptives
        • first-line
        • also first-line for treating hirsutism
      • metformin 
        • second-line agent
    • infertility
      • clomiphene citrate
        • first-line
    • glucose intolerance
      • metformin
Complications
  • Complications
    • infertility
    • endometrial hyperplasia and cancer
    • associated with increased insulin resistance


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TAG
(M1.RP.1) A 32-year-old female complains to her gynecologist that she has had irregular periods for several years. She has severe facial acne and dense black hairs on her upper lip, beneath her hairline anterior to her ears, and the back of her neck. Ultrasound reveals bilateral enlarged ovaries with multiple cysts. The patient is at increased risk of: Topic Review Topic

1. Hypothyroidism
2. Endometrial carcinoma
3. Addison’s disease
4. Wegener’s granulomatosus
5. Eclampsia

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