One of the most common endocrine
disorders facing a gynecologist. It is a heterogeneous disorder characterized
by disruption of the normal regular process leading to ovulation and presented
to the clinicians in a very wide range of symptoms and signs and some times
accidentally discovered by routine check up. Etiology and pathophysiology:-
The real cause of PCO is unknown
It is a familial condition possibly autosomal dominant, with premature balding
being the male phenotype.
It appears during increased weight gain during puberty , however the polycystic
ovary gene(s) has not yet been identified and the effect of environmental influences
such as weight changes and circulating hormone concentrations and the age at
which these occur is unknown.
Clinical presentation:-
PCO presents in various ways:-
1-Asymptomatic :- accidentally discovered with regular cycles , no signs of
metabolic and hormonal disturbances and only U/S findings of PCO which are 10 or more
cysts per ovary, 2-8 mm in diameter surrounding an echo dense stroma.
2- Weight gain (obesity)
Obesity is associated with high concentration of circulating leptin which is
a 167 amino acid peptide that is secreted by fat cells in response to insulin
and glucocorticoids. Obesity worsens both symptomatology and endocrine
profile so obese women with a body mass index BMI more than 30 kg /m2 should be encouraged to lose weight
Women with PCO have a greater frequency of hyperinsulinaemia and insulin resistance
Obese women with PCO have hyper secretion of insulin which stimulates ovarian
secretion of androgens.
3- Menstrual disturbances
* Primary or secondary amenorrhea.
* Irregular menstrual cycles
* Oligo menorrhea
4- Infertility:-
Hyper secretion of LH is particularly associated with menstrual disturbances
and infertility
5-Hyperandrogenism and hirsutism.
Symptoms of hyper androgenism include hirsutism which is characterized by
terminal hair growth in a male pattern of distribution including chin, upper
lip, chest, upper and lower back, abdomen, upper arm, thigh and buttocks.
A standardized scoring system such as the modified frerriman and gallwey score
should be used to evaluate the degree of hirsutism before and during treatment.
6-Recurrent abortions
7-Acne vulgaris
Laboratory Tests ad findings:-
- Increased androgens (testosterone and androstenedion)
The best method for diagnosing PCO is ultra sound examination and the vaginal
ultra sound gives 100 % detection rate as compared to 30% failure to detect PCO
by abdominal U/S. The characteristic finding is (10 or more small cysts measuring
2-8 mm in diameter surrounding an echo dense stroma)
Treatment:-
The treatment of PCO should be directed towards the symptoms and the presentation
of the disease.
1- Obesity:-
* Weight reduction
* Metformin tablets which inhibit the production of hepatic glucose and thereby
decrease insulin secretion.
* Low caloric diet is recommended for patients with BMI more than 30kg/m2 or for patients
with truncal obesity
2- Menstrual irregularity :-
The easiest way to control this problem is by using low dose combined oral contraceptive
preparations This will result in artificial non ovulatory cycles and regular shedding of the endometrium. An alternative is progesterone such as medroxyprogesterone acetate
or dydrogesterone for 5 days every 1-3 months to induce withdrawal bleeding.
3- Infertility: -
Ovulation can be induced by antiestrogenes, clomiphene citrate (5-100 mg) or
tamoxifen 20-40% mg days 2-6 of natural or induced bleeding, in resistant cases
we can use parenteral gonadotrophin therapy with very careful continuous
monitoring of the ovaries or we can use laparoscopic diathermy.
4- Hyperandrogenism and hirsutism :-
Treatment options include cosmetic and medical therapies. Medical therapy
stops further progression of hirsutism and decreases the rate of hair growth.
It
takes 6-9 months before any benefit is perceived and so physical treatment including
electrolysis, laser therapy, waxing and bleaching may be helpful during this
time until medical treatment shows any benefit.
Surgical treatment of PCO
1- Wedge resection of the ovaries
This procedure resulted in extensive adhesions and ovarian tissue loss so
it was replaced completely nowadays by laparoscopy
2- Laparoscopic ovarian diathermy
It is so effective with minimal damage to the ovaries, only minimal damage to
the ovary is required to stimulate ovulation.
Possible late sequels:-
* Diabetes Mellitus.
Findings are demonstrating that insulin resistance can be detected before the appearance
of other clinical findings of PCOS. Patients with PCOS findings, and in some
cases patients with only anovulation, are being tested for insulin resistance.
Our current testing includes a 12 hour fasting followed by a 75g glucose
challenge (sugar solution commonly used to test for gestational diabetes in
pregnancy). Blood level is drawn before the glucose is administered (fasting) and at 1 and 2 hours after
the glucose ingestion. The blood is evaluated for insulin and glucose.
Normally the fasting blood level will demonstrate normal range glucose and a low insulin level. After
a dose of sugar the blood glucose level increases as well as an increase in
secreted insulin. Abnormal values can indicate insulin resistance, and in some
cases, diabetes.
