The following article is summary of N Engl J Med 2016;375:54-64..
This was good opportunity for me to study pathological mechanism in PCOS (Polycystic ovarian syndrome).
Please be careful to use for clinical decision making. When you want to use these medical knowledge for real clinical situation, it is your responsibility and adapt for a particular condition.
Please be careful to use for clinical decision making. When you want to use these medical knowledge for real clinical situation, it is your responsibility and adapt for a particular condition.
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small ovarian follicles →hyper-secreated estradiol → stagnant follicular stage
classic PCOS affect 6-10% of women of reproductive age
heavy menstrual bleeding
① hyperandrogenism, hirsutism 70%
② ovulatory dysfunction→ unpredictable sense < 21 day or > 35 day, but 15-40% of hyperandrogegism has regular mense
③ polycystic ovarian morphologic features: > 12 antral follicles in either ovary, ovarian volume > 10 ml
30-50% insulin resistance, 8-10% DM, 50-80% obese
possibly increased risk of cardiovascular disease
risk of endometrial cancer 2.7 times, 9% of lifetime risk
sub-fertility: pregnancy without medical assistance is common, contraception used as indicated
Dx
①〜③ and exclusion; ex non classic congenital adrenal hyperplasia (early follicular-phase plasma 17-hydroxyprogesterone < 200 ng/dl → r/o 21-hydroxylase deficiency), androgen-secreting ovarian or adrenal tumors
diagnostic criteria is controversial
modified Ferriman-Gallwey score
free testosterone: most sensitive test for hyperandrogenemia with PCOS
androgen assays
Tx
combined estrogen progestin oral contraceptive pills
→ increase hepatic production of sex hormone-binding globulin, decreased free testosterone
30-35μg of ethinyl estradiol is effective managing hirsutism
additional:
spironolactone for hirsutism
episodic or continuous progestin for endometrial protection
metformin for abnormal glucose tolerance; 20-25% lower serum testosterone
clomiphene for ovulation induction
to prevent endometrial hyperplasia, recommend a course of progestin every 1-3 mon
or if contraception is required, daily progestin-only contraceptive pill, or levonorgestrel-releasing IUD
follow-up
screening for cardiometabolic risk: BMI, waist circumference, BP
fasting lipid level every 2yrs
screening for DM with 2-hour oral glucose-tolerance, every 1-5 yrs, depending on characteristics
screening for smoking, OSAS, depression, anxiety
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