This slides made by me presented in hospital under well recognised faculties of obstetrics and gynaecology. Thank You.

1. Polycystic Ovarian
Syndrome(PCOS)
Presented by:
Man Bahadur Darji
Final year medical student

2. Contents:
1. Introduction
2. Incidence
3. Pathophysiology
4. Pathology
5. Clinical features
6. Investigation
7. Treatment

3. Introduction
• Heterogeneous, multisystem endocrinopathy in women of reproductive
age
• First described by Stein and Leventhal in 1935 ( Stein-Leventhal
Syndrome)
• When fully expressed, manifestations include:
-Polycystic ovaries
-Androgen excess
-Ovulatory dysfunction
• Chronic anovulation resulting in infertility, irregular bleeding, obesity,
hirsutism

5. Pathology:
• Ovaries are enlarged with volume increased to >= 10 cm3
• Stroma is increased with thickened pearly white capsule
• Presence of multiple (>= 12) follicular cysts measuring about 2–9 mm
in diameter around the cortex
Histology:
• Thickening of tunica albuginea
• Cysts are at varying stages of maturation and atresia
• Theca cell hypertrophy (stromal hyperthecosis)
Fig: Multiple small peripheral cysts
are seen on the ovarian surface

6. Pathophysiology
• Hypothalamic — pituitary compartment abnormality
• Androgen excess
• Anovulation
• Obesity and insulin resistance
• Long-term consequences

7. Hypothalamic — pituitary compartment
abnormality

8. Androgen excess
• Abnormal regulation of the androgen forming enzyme P450 C 17
• principal sources are: Ovary, Adrenal, Systemic metabolic alteration
• Adrenals produce excess androgens by (i) stress (ii) P450 C17 enzyme
hyperfunction (iii) associated high prolactin level (20%)
• Hyperinsulinemia
• hyperprolactemia

9. Anovulation

10. Obesity and insulin resistance

12. Long-term consequences
• Diabetes mellitus (15%) due to insulin resistance
• Endometrial carcinoma due to persistently elevated level of
estrogens
• Hypertension and cardiovascular disease as dyslipidemia
(↓HDL,↑triglycerides, ↑LDL)
• Obstructive sleep apnea

13. CLINICAL FEATURES
• Young woman; Central obesity (BMI>30kg/m3)
• Oligomenorrhoea (87%), amenorrhoea (26%) followed by
prolonged or heavy periods. Dysmenorrhoea is absent
• Infertility (20%)
• Pregnancy loss (20–30%)
• Hyperandrogenism : Hirsutism, Acne, Acanthosis nigricans

14. On examination
• Obesity, Waist/hip ratio > 0.85 (abnormal)
• BMI between 25 and 30= overweight, above 30= obesity
• Blood pressure in obese women
• Thyroid enlargement
• Hirsutism, acne
• Acanthosis nigra (5%) over the nape of the neck, axilla and below the
breasts (manifestation of Hyperinsulinaemia)
• Pelvic findings are normal, and it is not common to palpate the enlarged
ovaries
14

15. Rotterdam Criteria
I. Oligo/amenorrhoea, anovulation, infertility
II. Hirsutism - acne
III. Ultrasound findings
• Performed in early follicular phase
• Enlarged ovaries, size, increased stroma
• 12 or more small follicles each of 2-9 mm in size placed
peripherally
• Rules out ovarian tumor
• Shows endometrial hyperplasia if present
• Ovarian volume >10 mm3
15

16. INVESTIGATION:
• Ultrasound is diagnostic of PCOS
It shows 12 or more small follicles each of 2–9 mm
in size placed
peripherally
It rules out ovarian
tumor
It shows endometrial
hyperplasia if present

17. • Serum values: (FSH, LH, TSH, Testosterone, glucose)
1. Elevated LH and/or LH:FSH>3:1
2. Increased estradiol and estrone(markedly elevated)
3. SHBG reduced
4. Increased androstenedione(3-5ng/mL)
5. Increased serum testosterone(>1.5 ng/ml) and DHEAS
6. Women with hirsutism have raised level of
dihydrotestosterone with presence of 5alpha reductase
7. Raised prolactin in 20%
8. Insulin Resistance:
Raised fasting insulin level >25uIU/ml
Fasting glucose/insulin ratio < 4.5
Insulin level, 2 hour post glucose(75 gm) >300uIU/ml
• Laparoscopy

18. Treatment
Purpose of treatment
• Treat irregular cycle
• Treat Hirsutism
• Treat Infertility
• Prevent long term effects

19. Weight reduction:
• Is first line treatment in obese
• BMI< 25 improves menstrual disorders, infertility, insulin resistance,
hyperandrogenism (hirsutism and acne) and obesity
• Improves metabolic abnormalities and reproductive functions
Lifestyle modifications:
• Abandon Cigarette smoking
Cigarette lowers E2 level and raises DHEA and
androgen level 19

20. For Irregular cycle :
• Oral combined pills (Low dose) E < 20mcg
• Progesterone of 3rd and 4th generation
• Oestrogen suppresses androgens and adrenal hormones and raises
SHBG
• Low dose combines pills, having progesterone with lesser androgenic
effect can be given
• If refuses OCPs- withdrawl of progesterone for 5 days

21. Hirsutism
OCP for 3 to 6 months
Progesterone -ve feedback on LH decreses Androgen
Estrogen increases SHBG
second choice:
Spirolactone: 100-200mg daily, best with OCP
3rd choice:
Cyproterone acetate: Combined with estrogen as 50-100mg cyproterone
daily for 1st 10 days of cycle with 30-50 μg of Ethinyloestradiol for 21 days
Acne
Clindamycin lotion 1% or erythromycin

22. Infertility
• Clomiphene citrate (old DOC)
• Letrozole (new DOC)
• hMG (Humegon, Pergonal) (FSH 75 IU + LH 75 IU)
• hCG (Profasi, Pregnyl)
• GnRH
• GnRH analogues
• Insulin Sensitizers: Metformin, Thiazolidiones
• Surgical Induction of Ovulation
• Laparoscopic Ovarian Drilling

23. Clomiphene citrate
• first line treatment for infertility in PCOS
• Selective Estrogen Receptor Modulator (SERM)
• Induce ovulation in 80% cases and 40-50% conceives
• Hyperstimulation in 10% cases
• Clomiphene with dexamethasone improves fertility rate

24. Competes with estrogen receptor in hypothalamus
▼
Blocks negative feedback of estrogen
▼
Normal pulsatile Release of GnRH
• LH
• FSH

25. • In normal cycles, the drug is started on the 2nd day of cycle to D6 or D5
to D9
• 50mg daily for 5 days (can be increased up to 150mg/day if lower dose
didn’t cause ovulation)
• Side effect of higher dose:
• Thickening of cervical mucus
• Antiestrogenic effect on endometrium
• Ovarian hyperstimulation Syndrome
• Multiple pregnancy

26. Tamoxifen
• In resistant cases  Tamoxifen 20– 40 mg daily for 5 days can be tried.
• Non steroidal anti-estrogenic drugs
• Acts by binding to and reducing availability of oestrogen receptors
• bone and cardio protective
• Used successfully in PCOS

27. Letrozole
• Aromatase inhibitors
• It inhibits the enzyme aromatase in the granulosa cells of ovarian
follicles
• Letrozole 2.5 mg from D2 to D6 increases the release of
gonadotropins from pituitary and stimulates development of ovarian
follicle
• Has no peripheral antiestrogenic effect on endometrium and cervical
mucus
• D10 follicular monitoring

28. Adavantage of letrozole over clomiphene
• Induces mono follicular stimulation
• No hyperstimulation syndrome
• Increase rates of live birth

29. Failure to above therapy then go for FSH, LH or GnRH analogues
• Hyperinsulinemia and Insulin Resistance:
-Treatment with metformin
• Elevated prolactin level:
-Bromocriptine or cabergoline
• Growth hormone-in case of elderly

30. • Pre-existing or induced elevated androgen
-Suppressed by dexamethasone 0.5 mg daily for 10 days, starting
from 1st day of cycle
• Conjugated estrogen 1.25 mg daily for 10 days starting on first day of
cycle is helpful
• hCG
-hCG 5000IU is adminstered 7 days after last dose of clomiphene
citrate due to failure of LH surge

31. Serial USG
• Daily increase in follicle size 1-2 mm
• When dominant follicle size > 20 mm, 5000 IU hCG IM given
• After 36-40 hrs after HCG  ovulation occurs (intercourse at this
time)

32. Gonadotrophin:
• Stimulate follicular growth
• hMG(human menopausal gonadotropin)
• Mixture of FSH and LH
• Started from any time from D2- D5 of the cycle
• Follicular growth is monitored with trigger hcg
Laparoscopic Ovarian drilling:
Burn stroma
Decrease androgen

33. References
• Padubidri V.G., Daftary S. N., Howkins and Bourne Shaw’s Textbook of
Gynaecology, 16th edition
• D.C, Dutta, Textbook of gynecology,7th edition

34. Thank You!!!