Gynecology: Polycystic Ovarian Syndrome (PCOS)

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I. General. Persistent anovulation produces polycystic ovaries and a hyper-androgenic state, associated with hyperinsulinemia and obesity. PCOS is also known as Stein-Leventhal syndrome and hyperandrogenemia with chronic anovulation.

II. History. Menstrual irregularities usually of teenage onset (patients often state that they never have had regular menses), hirsutism, acne, family history of PCOS (50% chance of first-degree female relatives being affected), or type II diabetes.

III. Physical. The traditional description of the patient with PCOS is an obese female with acne and excess body hair. However, not all women with PCOS have these manifestations and those with PCOS may be thin with a fair complexion. Patients may have palpably enlarged ovaries. Virilization is uncommon (deepened voice, etc.)

IV. Laboratory evaluation. Work-up of menstrual irregularities (as described under abnormal vaginal bleeding and secondary amenorrhea). LH:FSH ratio >2 or 3 suggests PCOS. Testosterone and DHEA-S levels may be mildly elevated. Consider endometrial biopsy at any age if prolonged amenorrhea or oligomenorrhea, and especially if >35.

V. Differential diagnoses. For hirsutism: late-onset adrenal hyperplasia, androgen-producing ovarian or adrenal tumors, Cushing’s syndrome, drug-induced, idiopathic hirsutism. For menstrual irregularities, see abnormal vaginal bleeding and secondary amenorrhea sections.

VI. Sequelae

A. Gynecologic. Infertility, amenorrhea, dysfunctional uterine bleeding, increased risk of endometrial cancer, possible increased risk of breast cancer.

B. Dermatologic. Hirsutism, alopecia, acne.

C. Cardiovascular. Lipid changes, increased risk of cardiovascular disease.

D. Endocrine. Increased risk of insulin resistance, leading to diabetes mellitus.

VII. Treatment. It is important that women with PCOS have menstrual periods at least every 3-4 months to reduce the risk of endometrial carcinoma.

A. Weight loss if achieved may reduce hirsutism and reverse menstrual irregularities and infertility.

B. Hormonal therapy. Weight loss may permit ovulation to resume. Treat menstrual irregularity with medroxyprogesterone or oral contracep- tives as described in previous sections. Can induce fertility with clomiphene.

C. Hirsutism. Weight loss, depilation, and electrolysis. Oral contraceptives may improve hirsutism (especially those with norgestimate). An alternative is Depo-Provera up to 400 mg IM Q3 months or medroxyprogesterone acetate 30-40 mg PO QD. Spironolactone is an anti-aldosterone diuretic and an antiandrogen, which can be used alone or with hormones. Give up to 100-200 mg PO QD (or in 2 divided doses) initially, reduce to maintenance dosage of 25-50 mg QD after results obtained. Monitor for hyperkalemia and use with effective contraception: spironolactone could feminize a male fetus. Second-line agents have more adverse effects: flutamide, finasteride.

D. Lipids. Consider screening for dyslipidemia with a fasting lipid panel.

E. Insulin resistance. Consider screening with a 75 g glucose tolerance test. If positive, metformin is useful to reduce insulin resistance, promote weight loss and prevent long-term complications.