Polycystic Ovary Syndrome

Introduction

Polycystic ovary syndrome (PCOS) is a heterogenous disorder characterized by a combination of clinical and/or biochemical hyperandrogenism, ovulatory dysfunction and/or polycystic ovarian morphology.

  • Additional features or associated conditions include obesity, hyperinsulinemia and infertility.
  • Consider the possibility of PCOS in females presenting with menstrual disturbance, hirsutism or premenopausal alopecia.

It is the most common endocrine disorder in women of reproductive age.



Clinical Presentation

Clinical presentation varies, with some women being asymptomatic and other women presenting with multiple dermatologic, glynaecologic and/or metabolic manifestations.

Women with PCOS typically present with

  • Clinical hyperandrogenism including hirsutism, acne and androgenetic alopecia.
  • Ovulatory dysfunction including abnormal menses and infertility
  • Obesity



Management

Therapy is individualized based on clinical presentation and patient goals, such as desire for pregnancy.

Lifestyle modification including weight control, changes to diet and/or physical activity is the first-line treatment for long-term outcome improvement (improved pregnancy rates, decreased hirsutism, and improvements in glucose levels) preceding and/or accompanying pharmacological treatment in women with PCOS.

Combined oestrogen-progestin oral contraceptives (COCs) are the main stay of pharmacologic therapy for women with PCOS for managing hyperandrogenism and menstrual dysfunction and for providing contraception.

Other options

  • Consider combination therapy (oral contraceptives plus antiandrogen) in hirsutism persists for ≥ 6 months or severe hirsutism. If additional cosmetic benefits are desired, consider permanent hair removal methods such as electrolysis or light-based therapies.
  • Metformin is a potential alternative to restore menstrual cyclicity as it restores ovulatory menses in approximately 30 to 50 percent of women with PCOS.
  • Consider topical creams (such as antibiotic cream, benzoyl peroxide, tretinoin or adapalene) in addition to hormonal contraceptives for management of acne. Alternatively, consider spironolactone as second-line therapy (spironolactone may cause feminization of male infants).
  • The first-line treatment of female pattern hair loss is with topical minoxidil. May consider adding antiandrogen therapy (in combination with effective contraception) to topical minoxidil.

Pharmacologic management of anovulation or infertility in women seeking to become pregnant.

  • Use letrozole as first-line treatment to improve ovulation, pregnancy and rate of live births.
  • If letrozole is not available or unable to be used, consider another medication for ovulation induction, such as clomiphene citrate plus metformin, clomiphene citrate alone or metformin alone.
  • Consider gonadotropins therapy (preferred) with ultrasound monitoring or laparoscopic ovarian drilling as second-line therapy.
  • If weight loss, ovulation induction with medications, and/or laparoscopic ovarian laser electrocautery are unsuccessful, the next step is in vitro fertilization (IVF).

NOTE: Clomiphene citrate had been the first-line drug for this population for many years, with metformin used as an alternative. However, both clomiphene and metformin appear to be less effective for live birth rates than letrozole



Prognosis

Women with polycystic ovary syndrome (PCOS) who are pregnant are reportedly at increased risk of gestational diabetes, preeclampsia, foetal macrosomia, small-for-gestational age infants, and perinatal mortality.



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