Question

Describe the pathophysiology, clinical manifestations, evaluation, and treatment of polycystic ovary syndrome (PC

Answer 1

Polycystic ovarian syndrome (PCOS, polycystic ovary syndrome) or polycystic ovarian disease (PCOD) is a common hormonal disorder that causes a number of different symptoms in women of reproductive age. The major symptoms of this condition is an irregularity in the menstrual cycle and the presence of excess male hormones (androgens).

The condition was named because of the finding of enlarged ovaries containing multiple small cysts (polycystic ovaries). Although most women with PCOS have polycystic ovaries, some affected women do not.

Pathophysiology:

The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs. The pathophysiology is mainly due to:

1) An alteration in gonadotropin-releasing hormone secretion results in increased luteinizing hormone (LH) secretion.: The altered GnRH levels promote the production of luteinizing hormone (LH) and result in a decrease in the production of follicle stimulating hormone (FSH). Patients with PCOS often exhibit an increase in the LH:FSH ratio, which may contribute to the ovarian excess of androgens relative to estrogens.

2) An alteration in insulin secretion and insulin action results in hyperinsulinemia and insulin resistance: 50-70% of patients with PCOS exhibit metabolic abnormalities, including poor glucose tolerance and hyperinsulinemia. Obesity and hormonal abnormalities add up to insulin resistance. Functional insulin resistance is considered a consequence of defects in insulin-mediated glucose transport and signaling in adipocytes and myocytes; this may be the result of a dysregulation in adipokine production and signaling from adipose tissues.

• Hyperandrogenism: arrest occurs when the granulosa cells of the ovaries normally begin to produce estrogen by aromatizing androstenedione produced by the theca cells; excess 5a-reduced androgens in the ovaries are thought to inhibit the action of aromatase and therefore reduce estradiol synthesis, which is required for further maturation
• Hyperinsulinemia: exacerbates ovarian hyperandrogenism by (1) increasing 17a-hydroxylase activity in theca cells and promoting androstenedione and testosterone production; (2) promoting LH- and IGF1-stimulated androgen production; and (3) elevating free testosterone by decreasing the production of sex hormone binding globulin (SHBG)

Clinical manifestations:

• Irregular periods: A lack of ovulation prevents the uterine lining from shedding every month. Some women with PCOS get fewer than eight periods a year
• Heavy bleeding: The uterine lining builds up for a longer period of time, so the periods you do get can be heavier than normal.
• Excess Hair growth (Hirsuitism): More than 70 percent of women with this condition grow hair on their face and body — including on their back, belly, and chest Acne. Male hormones can make the skin oilier than usual and cause breakouts on areas like the face, chest, and upper back.
• Baldness: Hair on the scalp gets thinner and fall out.
• Obesity: Up to 80 percent of women with PCOS are overweight or obese
• Darkening of the skin. Dark patches of skin can form in body creases like those on the neck, in the groin, and under the breasts.
• Headaches: Hormone changes can trigger headaches in some women.

Evaluation:

• Pelvic exam.:The doctor visually and manually inspects your reproductive organs for masses, growths or other abnormalities.
• Blood tests: Blood may be analyzed to measure hormone levels. This testing can exclude possible causes of menstrual abnormalities or androgen excess that mimics PCOS. Also blood testing to measure glucose tolerance and fasting cholesterol and triglyceride levels.
• An ultrasound: The appearance of ovaries and the thickness of the lining of your uterus are assessed. This is definitive diagnostic measure for PCOD.

Treatment:

1. Life style changes: Weight loss through a low-calorie diet combined with moderate exercise activities. Even a modest reduction in your weight — for example, losing 5 percent of your body weight — might improve your condition. Losing weight may also increase the effectiveness of medications. The reduction of the abdominal circumference and thigh circumference are considered essential in weight loss.
2. Medications:

• Combined Estrogen and Progestin pills helps to reduce androgen production and regulate estrogen. Instead of pills, a skin patch or vaginal ring that contains a combination of estrogen and progestin are also available.
• Progestin only pill: Taking progestin for 10 to 14 days every one to two months can regulate your periods and protect against endometrial cancer.
• Metformin (Glucophage, Fortamet, others). This oral medication for type 2 diabetes improves insulin resistance and lowers insulin levels.
• Clomiphene (Clomid). This oral anti-estrogen medication is taken during the first part of your menstrual cycle.
• Letrozole (Femara). This breast cancer treatment can work to stimulate the ovaries.
• Spironolactone (Aldactone). This medication blocks the effects of androgen on the skin. Spironolactone can cause birth defect, so effective contraception is required while taking this medication.
• Electrolysis. A tiny needle is inserted into each hair follicle. The needle emits a pulse of electric current to damage and eventually destroy the follicle. Patient needs multiple sittings for the treatment.