Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definition
Incidence
Aetilogy and Pathogenesis
Clinical Assessment
History
Examination
Investigations
Treatment
Medical
Surgical
Complications
Prognosis
Definition
PCO is an ultrasound diagnosis – If at least one ovary has 12 or more small peripheral cysts (2–8 mm) the woman is said to have PCO.
PCOS is present in a woman who has PCO on ultrasound, and has one or more of the symptoms of hyperandrogenism. This includes oligomenorrhoea, excess hair growth, pimples/acne. greasy skin.
Incidence
Population studies have shown that Caucasian women have a 20–25 % incidence of PCO. In women from the Indian and Asian subcontinents, the incidence can be as high as 50 %.
Aetilogy and Pathogenesis
The inheritance of PCO is poorly understood, but appears to be multifactorial. Whilst there is a familial trend, a PCO gene has not been identified.
Pathogenesis appears to commence with an excess of LH secretion, resulting in hyperandrogenism (encouraging the circulating steroids to be metabolised to androgens) which then promotes a degree of insulin resistance.
Clinical Assessment
Fifty percent of women with PCO have no symptoms or signs. Gaining weight and becoming less active appear to be mechanisms which may precipitate the transition from PCO to PCOS.
History
· Menstrual irregularity – this is the commonest and earliest symptom of PCOS. This can be oligomenorrhoea or secondary amenorrhoea. Women may present with subfertility (due to irregular/anovulation) as their primary concern.
· Acne/greasy skin- is the second commonest symptom, and the majority of teenage girls who are seen by dermatologists for acne have PCOS.
· Hirsuitism – women with PCOS often complain of excess hair growth and having to remove hair, especially from the upper lip, lower abdomen, and arms..
· Obesity – Many women with PCOS have a significant problem controlling their weight. Classically they have central obesity, with the distribution being apple rather than pear shape.
Examination
· General examination will reveal the manifestations of the symptoms identified on history.
The degree of hirsuitism can be quantitated by using the Ferriman- Gallwey score. This is a quantitative assessment of hair growth, scoring one to four in 11 different body parts, namely the upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm, forearm, thigh, and lower leg.
· Vaginal examination is not helpful in the diagnosis. Although the ovaries are often enlarged, they are not palpable.
Investigations
Ultrasound
The definitive diagnostic investigation is ultrasound. Ideally this should be transvaginal. According to the criteria decided at a consensus conference of international experts (ESHRE-ASRM), PCO is diagnosed if twelve or more small follicles, 2–8 mm in diameter, are present in at least one ovary. In addition, the ovaries are usually enlarged (>10 cm3), and there is increased stromal density.
Hormone Levels
Classically there is an LH:FSH ratio greater than 2:1
Androgenic hormones – testosterone, dehydroepiandrostendione (DHEA) and androstenedione are often elevated. The results of these tests will not change the management, so their measurement is not essential.
Glucose Levels/Insulin Resistance
Some women with PCOS, especially ones who are obese, have some degree of insulin resistance. This is diagnosed by a raised fasting blood sugar or an elevated HbA1c.
Treatment
The treatment depends on what the problem is.
In general, the first line of treatment should be diet and exercise. In obese women with PCOS, weight loss will improve menstruation, acne and hirsuitism. Some studies have shown restoration of ovulation and resolution of subfertility in association with weight loss.
Medical
Hormonal
· Anovulation – If she wishes to conceive, then ovulation induction can be undertaken (see Chap. 16).
· Menstrual irregularity: to protect the endometrium – COC, cyclical progestogen, or LNG-IUS insertion (See Chap. 15)
Acne and/or Hirsuitism
An anti-androgenic COC e.g. a “pill” containing cyproterone acetate or drospirinone and ethinyl oestradiol or high dose Cyproterone acetate (100 mg/day) for ten days a month, in conjunction adequate contraception.
Surgical
Minor
Ovarian cautery can be used to induce ovulation – see Chap. 16.
Various cosmetic approaches such as waxing, shaving, and laser therapy can be utilised to improve symptoms of hirsuitism.
Major
Rarely women with PCOS and HMB which does not respond to conservative measures may require hysterectomy.
Bariatric surgery to reduce stomach capacity and limit eating can be successful in achieving weigh reduction, with a subsequent improvement in symptoms.
Surgical removal of the ovaries does not solve the problem, as PCOS is a metabolic condition affecting all organ systems, not just the ovaries.
Complications
Women with PCOS are at a higher risk of developing diabetes and endometrial cancer. An increased risk of cardiovascular disease has not been proven unequivocally, although surrogate markers e.g. lipids are often elevated.
Prognosis
PCO/PCOS cannot be cured because it is not a disease. However, the abnormality is imprinted in every cell of the body. The best one can do is to provide symptomatic treatment, or at least minimise the symptoms and signs.