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Polycystic Ovary DiseaseAka: Stein-Leventhal Syndrome, Polycystic Ovary Syndrome, Polycystic Ovaries, Functional Ovarian Hyperandrogenism, PCO Disease, PCOS

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  1. See Also
    1. Hyperandrogenism
    2. Insulin Resistance Syndrome
    3. Dysfunctional Uterine Bleeding
  2. History
    1. First described by Stein and Leventhal in 1935
  3. Pathophysiology
    1. Contributing Factors
      1. Obesity and hyperinsulinemia
      2. Increased adrenal function
    2. Androgen Excess (Hyperandrogenism)
      1. Androstenedione increased
      2. Testosterone increased
      3. Free Testosterone increased
        1. Occurs with decreased Sex Hormone Binding Globulin
    3. Ovarian enlargement with Hyperthecosis
      1. Luteinization of theca interna
      2. Reduction of granulosa cells
  4. Symptoms
    1. Menstrual Disorders (80% of PCOS patients)
      1. Anovulatory Bleeding (<6 Menses per year)
      2. Delayed menstrual regularity
    2. Infertility (74%) and Recurrent Miscarriage
    3. Androgenic features
      1. See Hyperandrogenism
      2. Acne Vulgaris
      3. Hirsutism (69%)
      4. Male sweat changes
      5. Clitoris swelling
    4. Central Obesity (49% of PCOS patients)
      1. Weight gain starts in teens and twenties
      2. BMI over 27 (65% of PCOS patients)
    5. Mood disturbance (e.g. Major Depression, Anxiety)
  5. Signs
    1. Hirsutism
    2. Bilateral ovary enlargement
    3. Hypertension
  6. Differential Diagnosis (See Hyperandrogenism)
    1. Cushing's Syndrome and other endocrinopathies
    2. Adrenal Hyperplasia
    3. HAIR-AN Syndrome
  7. Radiology: Transvaginal Ultrasound
    1. General features
      1. Multiple small follicles in various stages
      2. Thick ovarian capsule
      3. String of pearls appearance
    2. Criteria: Multiple Ovarian Cysts (seen in 80% of cases)
      1. Ten or more cysts in a single plane
      2. Each cyst <10 mm in diameter
      3. Dense stroma
    3. Interpretation
      1. Polycystic appearance is seen in up to 33% of women
      2. Polycystic appearance does not diagnose PCOS
      3. PCOS clinical features must be present for diagnosis
      4. Hassan (2003) Fertil Steril 80:966
  8. Labs: Approach
    1. Screening for PCOS (if history suggests)
      1. Glucose to Insulin Ratio < 4.5
    2. Exclude other diagnoses
      1. Thyroid Stimulating Hormone
      2. Morning 17a-hydroxyprogesterone (adrenal hyperplasia)
      3. Serum DHEAS > 700 ng/dl (Androgen secreting tumor)
      4. Serum Total Testosterone >20 ng/dl (Androgen tumor)
    3. Evaluate comorbid disease
      1. Fasting Glucose
      2. Fasting Lipid Panel
  9. Labs: Review of laboratory changes in PCOS
    1. Insulin Resistance Syndrome (70% of PCOS patients)
      1. Glucose to Insulin Ratio < 4.5
        1. Sensitive marker of Insulin Resistance in PCOS
      2. Insulin increased (C-Peptide increased)
      3. Fasting Serum Glucose increased
      4. Two hour Glucose Tolerance Test abnormal
    2. Gonadotropin increases
      1. Luteinizing hormone (LH) exaggerated surge
      2. Serum LH to Serum FSH ratio exceeds 3.0 (30%)
      3. Serum Testosterone >20 ng/dl
      4. Serum Free Testosterone >2.57 pg/ml
      5. Androstenedione >2.7 ng/ml
    3. Associated endocrine abnormality testing
      1. Thyroid Stimulating Hormone (TSH)
      2. Serum Prolactin
      3. Consider adrenal function testing
    4. Associated dyslipidemia
      1. Total Cholesterol increased
      2. LDL Cholesterol increased
      3. HDL Cholesterol decreased
      4. Triglycerides increased
  10. Management: Initial
    1. Weight loss of 10% in overweight patients
      1. Insulin Resistance decreases with weight loss
        1. Kiddy (1992) Clin Endocrinol 36:105
      2. Results in 75% conception rate in PCOS
        1. Bates (1982) Fertil Steril 38:406
    2. Unopposed Estrogen Management
      1. Provera 10 mg PO qd for 7 days repeated q3 months or
      2. Oral Contraceptive with low Androgenic Activity
        1. Ortho Tri-Cyclen
        2. Ortho-Cept or Desogen
        3. Modicon
        4. Ortho-Cyclen
        5. Yasmin
    3. Management of Hyperandrogenism (e.g. Hirsutism, Acne)
      1. Similar management to HAIR-AN Syndrome
      2. Consider Spironolactone (Aldactone) 50 mg PO bid
      3. Consider Hirsutism Management
    4. Management of Insulin Resistance
      1. Metformin (Glucophage)
        1. Start at 500 mg PO qd and advance to tid
        2. Effect not seen until dose >1000 mg/day
        3. Induces Ovulation in up to 46% of PCOS cases
      2. References
        1. Barbieri (2003) Obstet Gynecol 101:785
        2. Lord (2003) BMJ 327:951
  11. Management: Advanced
    1. Clomiphene Citrate with or without HCG
      1. Indicated for Ovulatory Dysfunction
    2. Gonadotropins (e.g. Metrodin, Pergonal)
      1. Risk of Ovarian Hyperstimulation Syndrome (OHSS)
    3. FSH with hCG
    4. Glucocorticoids (Prednisone, Dexamethasone)
      1. Indicated in adrenocortical hyperplasia
    5. Dopamine agonist (Parlodel)
      1. Indicated for Hyperprolactinemia
    6. GnRH-agonist
      1. Indicated prior to Ovulation induction
  12. Management: Surgical
    1. Ovarian wedge resection
      1. Normal cycles resume in 80% of patients
      2. Conception occurs in 63%
      3. Risk of peritubular and ovarian adhesions
    2. Laparoscopic ovarian drilling
      1. Similar results to ovarian wedge resection
      2. Minimally invasive
  13. Complications
    1. Infertility
    2. Increased Breast Cancer risk
    3. Increased Endometrial Cancer risk
      1. Associated with unopposed Estrogen
    4. Increased cardiovascular disease risk
  14. References
    1. Acien (1999) Fertil Steril 72:32
    2. Chang (1999) Endocrinol Metab Clin North Am 28:397
    3. Futterweit (1999) Obstet Gynecol Surv 54:403
    4. Pasquali (1999) Clin Endocrinol 50:517
    5. Richardson (2003) Am Fam Physician 68(4):697
    6. Taylor (1998) Endocrinol Metab Clin North Am 27:877

Polycystic Ovary Syndrome (C0032460)

Definition (MSH)A complex disorder characterized by infertility, HIRSUTISM; OBESITY; and various menstrual disturbances such as OLIGOMENORRHEA; AMENORRHEA; ANOVULATION. Polycystic ovary syndrome is usually associated with bilateral enlarged ovaries studded with atretic follicles, not with cysts. The term, polycystic ovary, is misleading.
Definition (CSP)clinical symptom complex characterized by presence of multiple cysts on the ovaries, oligomenorrhea or amenorrhea, anovulation and regularly associated with excessive amounts of body hair (hirsuitism), excessive body weight, infertility and insulin resistance.
ConceptsDisease or Syndrome (T047)
ICD9256.4, 256.4
MSHD011085
EnglishBILATERAL POLYCYSTIC OVARIAN SYNDROME, Cystic disease of ovaries, Multicystic ovaries, PCO, PCO - Polycystic ovaries, PCO1, PCOD - Polycystic ovarian disease, PCOS, PCOS - Polycystic ovarian syndrome, PCOS1, Polycystic ovarian disease, Polycystic ovarian syndrome, Polycystic ovaries, polycystic ovary, POLYCYSTIC OVARY DISEASE, polycystic ovary disorder, Polycystic Ovary Syndrome, POLYCYSTIC OVARY SYNDROME 1, POYCYSTIC OVARIAN SYNDROME, Sclerocystic Ovarian Degeneration, SCLEROCYSTIC OVARIAN DISEASE, Sclerocystic Ovary Syndrome, Stein - Leventhal syndrome, Stein Lenventhal syndrome, Stein Leventhal Syndrome, Stein-Leventhal synd., Stein-Leventhal syndrome
Spanishenfermedad quistica de los ovarios, ovarios poliquisticos, poliquistosis ovarica, sindrome de Stein - Leventhal
Parent ConceptsEndocrine System Diseases (C0014130), Ovarian Cysts (C0029927), Syndrome (C0039082), Disorder of endocrine ovary (C0154208), Polycystic Ovary Syndrome (C0032460), Ovarian Non-Neoplastic Disorder (C1335173), Hyperandrogenism (C0206081), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesCOSTAR, CSP, DXP, ICD9CM, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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