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15

Polycystic Ovarian Syndrome (PCOS) is a

very common condition affecting at least

14% of all women of reproductive age.

In 2003, the Rotterdam ESHRE/ASRM

Consensus Group revised Diagnostic

Criteria for PCOS which are:

1. Oligo- and/or anovulation

2. Hyperandrogenism (Clinical [hirsutism,

acne] and/or biochemical)

3. Polycystic ovaries (at least 10 antral

follicles in periphery ± increased

ovarian stroma)

2 out of 3 criteria are required for

diagnosing the syndrome

Aetiology

• Unknown but results from a

combination of several related factors.

•Women with PCOS frequently

have a mother or sister with PCOS.

But there is not enough evidence

yet to say there is a genetic link to

this disorder.

• An imbalance between the pituitary

gonadotropin luteinizing hormone

(LH) and follicle-stimulating hormone

(FSH), resulting in a lack of ovulation

and an increased testosterone

production, a male sex hormone.

• Many women with PCOS have a

weight problem. So researchers are

looking at a relationship between

PCOS and the body’s ability to

make insulin. Insulin is a hormone

that regulates the change of sugar,

starches and other food into energy

for the body’s use or for storage.

Many women with PCOS have

insulin resistance, in which the body

cannot use insulin efficiently. Since

some women with PCOS make

too much insulin, this leads to high

circulating blood levels of insulin,

called hyperinsulinemia. It is believed

that hyperinsulinemia is related to

increased androgen levels and it is

possible that the ovaries react by

making too many male hormones,

androgens.This can lead to acne,

excessive hair growth, weight gain

(obesity), and ovulation problems as

well as type 2 diabetes. In turn, obesity

can increase insulin levels, causing

PCOS to get worse.

Treatment of PCOS

Lifestyle change and change in diet are

absolutely paramount.The long-term

consequences of PCOS should also

be highlighted. Prophylactic use of

Metformin in women with impaired

glucose tolerance to prevent progression

of diabetes is gaining increasing acceptance.

The effectiveness of Metformin, in relation

to ovulation induction, has been evaluated

and the most recent meta-analysis of

27 trials (Moli et al November 2007)

concluded that Clomiphene Citrate

(CC) should still be the first choice

therapy for women with therapy naïve

PCOS (no previous treatments). In CC

resistant women, a combination of CC

plus Metformin is more effective than

laparoscopic ovarian drilling or FSH.

Polycystic Ovarian Syndrome

What’s New?

Symptoms:

• Irregular periods (cycle greater than

35 days or lack of periods).

• Irregular ovulation or no ovulation.

• Infertility; difficulty in becoming

pregnant.

• Recurrent miscarriages.

• Unwanted facial and/or body hair

(hirsutism).

• Oily skin, acne.

• Being overweight, rapid weight gain

especially around the waist and

abdomen (central obesity); difficulty

in losing weight.

Investigation of PCOS:

• Transvaginal Ultrasound (specific

reporting on numbers of antral

follicles essential).

• FSH/LH ratio (on day 3-5 of menses

or after progesterone challenge, avoid

mid-cycle day 18-20 in women with

cycles less than 35 days).

• Androgen profile.

• Oral glucose tolerance test if BMI

>27 /Thyroid function tests.

• Lipid profile (cholesterol, LDL and

triglycerides).

CONSULTANT

SYNOPSIS

Mr Joseph Aquilina FRCOG is

a Consultant Obstetrician and

Gynaecologist at St.Bartholomew’s

and The Royal London Hospitals.

He provides a specialist service

in Gynaecological Ultrasound and

is recognised as a Preceptor for

training in gynaecological scanning by

the Royal College of Obstetricians

and Gynaecologists. He offers a

comprehensive one-stop service

in the management of menstrual

disorders, pelvic pain and polycystic

ovarian syndrome. He is available

for consultations at London Bridge

Hospital on Tuesday afternoons/early

evenings. Appointments can be made

by telephoning Mr Aquilina’s personal

assistant on

020 8504 5381

(Tel/Fax)

or email

[email protected]

.

Take home messages:

• Presenting symptoms are highly variable.

• Not all women with PCOS are infertile.

• Treatment of PCOS is highly

individualised.

• Lifestyle changes and exercise are

mandatory as part of the management

of the condition.

• Metformin may have a role in treatment

of POC and a six-month trial is

worthwhile, especially in obese PCOS.

• For women requesting cycle control, oral

contraceptive pill with anti-androgen

activity (Yasmin) should be offered.

• Clomiphene is the initial treatment of

choice in infertility.

• Clomiphene plus Metformin may be

more effective than ovarian drilling or IVF.

Conclusion

PCOS is a very common problem that

has both short-term effects upon

reproductive function and longer term

effects upon the risk of diabetes and

cardiovascular disease. Challenges for

the future are the management of

overweight adolescents with PCOS

and the use of Metformin as an adjunct

to IVF treatment in women with PCOS

and its use in antenatal period.