Polycystic Ovarian Syndrome: Management

Laya Charara
February 9, 2016

Background

Disorder characterized by hyperandrogenism,

ovular dysfunction, and polycystic ovaries.

Significant metabolic sequelae associated with the

condition, including diabetes, cardiovascular
disease, dyslipidemia, and obesity.

Anovulatory infertility, hirsutism, and acne are

additional manifestations.

Etiology
Genetic contribution uncertain.
Insulin resistance may be central to the
etiology of the syndrome.

Differential Diagnoses

Androgen secreting tumor

Exogenous androgens
Cushing syndrome
Nonclassical congenital adrenal hyperplasia
Acromegaly
Primary hypothalamic amenorrhea
Thyroid disease
Prolactin disorder

Diagnostic Criteria

Criteria include: hyperandrogenism,

oligoamenorrhea or amenorrhea, polycystic
ovaries by US diagnosis.

National Institutes of Health Criteria (both are

required for diagnosis)

Rotterdam Consensus Criteria (two out of three

are required for diagnosis)

Androgen Excess Society (hyperandrogenism plus

one out of remaining two are required for
diagnosis)

Diagnostic Evaluation

Physical Exam: BP, BMI, presence of signs of hyperandrogenism.

Lab:

total testosterone
free testosterone
TSH
prolactin
Evaluate for metabolic abnormalities (glucose tolerance test, fasting lipid
and lipoprotein levels).

Imaging: US --> in one or both ovaries, 12 or more follicles measuring 2-9

mm, or increased ovarian volume (> 10 cm^3)

Treatment Objectives

Amelioration of hyperandrogenic symptoms

Ovulation induction for women pursuing

pregnancy

Managing underlying metabolic abnormalities

Preventing endometrial hyperplasia and carcinoma
Contraception for those women with
oligomenorrhea who do not wish to become
pregnant

Non-pharmacologic
Treatments

Diet and exercise with a goal of weight-

reduction is first line in treating obese and

overweight women with PCOS.

Demonstrated improvement of insulin

resistance, regulation of menstrual cycles

upon lifestyle modification.

Pharmacologic
Treatments
Broken down for two patient
groups: the women not pursuing
pregnancy and the women who are
pursuing pregnancy.

Women not pursuing

pregnancy
Estrogen-progestin contraceptives are

mainstay treatment for this group. Provides

endometrial protection from chronic
anovulation.

Possible cutaneous benefits for

hyperandrogenism (acne, hirsutism).

Contd.
Metformin is considered a second-line
therapy for this group of patients.

Can reduce insulin levels in women with

PCOS.

Currently inadequate evidence to

recommend the routine addition of

metformin to oral contraceptive therapy.

Women pursuing
pregnancy

Stress lifestyle modification for this group as well as first

line treatment.

Clompiphene citrate: Anti-estrogen drug. First line

treatment for anovulatory women. Pregnancies shown to
occur within first six ovulatory cycles.

Gonadotropins: induce ovulation for women who

failed on clomiphene. Low-dose regimen.

Aromatase inhibitors: letrozole and anastrazole ->

primary and secondary treatments. Not yet FDA
approved for this purpose.

Surgical Therapy
Wedge resection of ovaries historically
done.

No longer recommended due to postoperative adhesions.

Laparoscopic ovarian laser electrocautery

can be done.

u-WISE questions
A 26-year-old G0 woman presents with hirsutism and irregular menses. Her mother,
who is diabetic, had similar complaints prior to menopause. On physical exam, this
patient is noted to have terminal hair on her chin and a gray-brown velvety
discoloration on the back of her neck. This lesion is acanthosis nigricans. Which of the
following is the most appropriate first test to order for this patient?
A. Fasting insulin
B. TSH
C. 17-hydroxyprogesterone level
D. Cortisol level
E. Pelvic ultrasound

Question 2
A 23-year-old nulliparous woman presents to the office because she has not
had any menses for four months. She has a long history of irregular menstrual
cycles since menarche at age 14. She is in good health and is not taking any
medications. She is sexually active with her partner of six months, and uses
condoms for contraception. She is 5 feet 4 inches tall and weighs 170 pounds.
On exam, she has noticeable hair growth on her upper lip and chin. The rest of
her examination including a pelvic exam is normal. Her Beta-hCG is < 5 mIU/
mL, and her prolactin and TSH levels are normal. In addition to recommending
weight loss, what is the most appropriate next step in the management of this
patient?
A. Treatment with gonadotropin releasing hormone level (GnRH) agonist
B. Treatment with clomiphene citrate
C. Treatment with oral contraceptives
D. Check progesterone levels
E. Check cortisol levels

Question 3
A 32-year-old nulliparous woman presents with amenorrhea for the last three
months. She has a long history of irregular cycles, 26 to 45 days apart, for the
last two years. She is otherwise in good health and is not taking any
medications. She is sexually active with her husband and uses condoms for
contraception. She is 5 feet 4 inches tall and weighs 140 pounds. On exam, she
has a slightly enlarged, non-tender uterus. There are no adnexal masses. Which
of the following is the most appropriate test to obtain in this patient?
A. Thyroid stimulating hormone (TSH)
B. Progesterone and estrogen
C. Follicle stimulating hormone and luteinizing hormone levels (FSH and LH)
D. Urine pregnancy test
E. Pelvic ultrasound

References

Barbieri, RL. Treatment of polycystic ovary syndrome in adults. In:

UpToDate. (Accessed on January 13, 2016).

ACOG Practice Bulletin No. 108: polycystic ovary syndrome.