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Polycystic Ovarian Syndrome

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leads to overproduction of testosterone & Androstenedione. Polycystic Ovarian Syndrome ... Androstenedione. Free testosterone. Pelvic Ultrasound. use to detect ... – PowerPoint PPT presentation

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Title: Polycystic Ovarian Syndrome


1
Polycystic Ovarian Syndrome Hirsutism
  • Walter Eisenhauer MMSc, PA-C

2
Polycystic Ovarian Syndrome
  • Formerly called Stein Leventhal Syndrome (1905)
  • Characterized by
  • anovulatory bleeding/amenorrhea
  • hirsutism,
  • obesity,
  • hyperinsulinemia/insulin resistance,
  • bilateral ovarian enlargement multiple cysts
  • Infertility
  • Hyperandrogenemia Hyperestrogenemia (due to
    peripheral conversion)

3
Polycystic Ovarian Syndrome
  • Patients are obese and manifest insulin
    resistance- frank diabetes is rare
  • Infertility75 of cases
  • Hirsutism70 of cases
  • Amenorrhea50 of cases

4
Polycystic Ovarian Syndrome
  • Pathophysiology
  • incompletely understood
  • abnormally elevated LH levels
  • loss of mid cycle LH surge
  • Excessive androgen production
  • Atresia of ovarian follicles
  • Ratio of LHFSH markedly increased

5
Polycystic Ovarian Syndrome
  • Inciting events are unknown and may differ from
    one person to the next
  • Disturbance in hypothalamic-pituitary function is
    postulated
  • Hyperinsulinism hyperandrogenism appear related
    but incompletely defined

6
Polycystic Ovarian Syndrome
  • Affects 5 of reproductive age women
  • Represents a leading cause of chronic anovulatory
    bleeding
  • disorder of hypothalamic rhythmicity
  • excessive LH production without mid cycle surge
  • leads to overproduction of testosterone
    Androstenedione

7
Polycystic Ovarian Syndrome
  • Androgens converted to estrone which causes
    endometrial proliferation that results in
    irregular periods
  • Serum concentrations of both estrogen and
    testosterone rise
  • Insulin resistance once believed to be due to
    ovarian androgen overproduction
  • Current theory is that Hyperinsulinism causes
    ovarian androgen overproduction

8
Polycystic Ovarian Syndrome
  • Consequence of androgen overproduction
  • hirsutism
  • frank virilization
  • Chronic unopposed estrogen stimulation leads to
    endometrial Hyperplasia, cellular atypia, and
    endometrial carcinoma

9
Polycystic Ovarian Syndrome
  • Risk of endometrial carcinoma increased threefold

10
Polycystic Ovarian Syndrome
  • History
  • Complete a good menstrual history
  • menarche
  • duration, frequency, intensity of bleeding
  • periods always irregular or new onset
  • menorrhagia/metrorrhagia
  • Sx of pregnancy
  • Attempt to determine if irregular bleeding
    ovulatory or anovulatory

11
Polycystic Ovarian Syndrome
  • History
  • Ovulatory bleeding suggested by presence of
    premenstrual symptoms
  • breast engorgement
  • pelvic cramping
  • fluid retention
  • mood swings
  • Menstrual regularity more suggestive of ovulatory
  • Family Hx of PCO

12
Polycystic Ovarian Syndrome
  • Anovulatory
  • absence of premenstrual symptoms
  • frequently long periods of amenorrhea followed by
    irregular bleeding

13
Polycystic Ovarian Syndrome
  • If bleeding thought to be anovulatory ask the
    following
  • precipitated by emotional stress?
  • Recent weight loss?
  • Exercise?
  • chronic illness?
  • Rapid onset of hirsutism and virilization
    suggestive of adrenal or ovarian tumor secreting
    androgens

14
Polycystic Ovarian Syndrome
  • Life long history of irregular menses, hirsutism,
    infertility, and obesity is suggestive of PCO

15
Polycystic Ovarian Syndrome
  • Physical Examination
  • General
  • seek s/s of virilization
  • Skin
  • changes suggestive of thyroid disorders
  • Hair
  • Neuro
  • Pituitary tumors may cause bitemporal
    hemianopsia, headaches other focal neuro findings

16
Polycystic Ovarian Syndrome
  • Pelvic
  • ovarian enlargement-irregularity suggestive of
    cysts
  • clitoral hypertrophy
  • Breasts
  • Galactorrhea
  • Suggestive of hyperprolactinemia

17
Polycystic Ovarian Syndrome
  • Laboratory testing(the following may be elevated
    and the only chemical evidence supporting PCO)
  • Estrone
  • Androstenedione
  • Free testosterone
  • Pelvic Ultrasound
  • use to detect polycystic ovaries

18
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19
Polycystic Ovarian Syndrome
  • Two hour post prandial glucose
  • Lipid studies

20
Polycystic Ovarian Syndrome
  • Treatment
  • Reduce risk of endometrial cancer by
    administering monthly/bimonthly course of
    medroxyprogesterone to induce menstrual bleeding
  • Infertility
  • Old therapy wedge resection of ovaries (only
    brings short term relief)
  • Still used

21
Polycystic Ovarian Syndrome
  • Treatment
  • Infertility
  • Clomiphene
  • Prednisone
  • Oral contraceptives
  • spironolactone
  • Hyperinsulinemia
  • weight loss
  • exercise
  • oral hypoglycemics

22
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23
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24
Hirsutism
  • Definition
  • Increase in transformation from vellus to
    terminal hair
  • Dont confuse with Non androgen dependent
    increase in hair known as
  • Familial hypertrichosis
  • vellus hair only
  • face and trunk
  • Managed by mechanical hair removal only

25
Normal Hair Growth
  • Hair grows cyclically not continuously
  • Anagen-rapid growth
  • Catagen-involution
  • Telogen- resting stage

26
Hirsutism
  • Androgen dependent
  • Male pattern hair growth
  • respond best to combination therapy(hair removal
    and meds)
  • 95 have both adrenal and ovarian causes
  • PCO most common

27
Hirsutism
  • Causes of hirsutism
  • Adrenal tumors
  • Congenital adrenal hyperplasia
  • Cushing's syndrome
  • Medications (eg, Cyclosporine, anabolic steroids)
  • Ovarian tumors
  • Polycystic ovary syndrome
  • Racial or ethnic background

28
Hirsutism
  • History
  • Menstrual
  • Family history
  • Meds
  • Endocrine review of systems

29
Hirsutism
  • Physical Examination
  • General
  • Endocrine
  • Abdomen
  • Pelvic
  • Skin

30
Hirsutism
  • Lab evaluation
  • Testosterone levels
  • DHEA
  • 24 hour free cortisol/dex suppression test
  • Imaging studies of ovaries/adrenals

31
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32
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33
Hirsutism
  • Guidelines for the Treatment of Hirsutism
  • Polycystic ovary syndrome
  • Oral contraceptives (Demulen 1/35, Desogen,
  • Ortho-Cept, Ortho-Cyclen or Ortho Tri-Cyclen)
  • Spironolactone (Aldactone), 50 to 100 mg two
    times per day

34
Hirsutism
  • Idiopathic
  • Oral contraceptives
  • (Demulen 1/35, Desogen, Ortho-Cept, Ortho-Cyclen
    or Ortho Tri-Cyclen)
  • Spironolactone, 50 to 100 mg two times per day
  • Nonclassic
  • Glucocorticoids prednisone, 5 mg every night
  • Congenital adrenal hyperplasia
  • dexamethasone, 0.25 mg every night at bedtime
  • Cushing's syndrome
  • Surgical excision of ACTH-secreting pituitary

35
Hirsutism
  • adenoma or ectopic ACTH-secreting tumor
  • adrenalectomy for adrenal hyperplasia
  • Adrenal tumor
  • Surgical excision
  • Ovarian tumor
  • Surgical excision
  • Drug-induced
  • Discontinue medication

36
Hirsutism
  • Polycystic ovary syndrome
  • Finasteride (Proscar), 5 mg per day, GnRH
    agonist (Lupron Depot), 3.75 mg monthly
  • Idiopathic
  • Finasteride, 5 mg per day
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