• Polycystic ovarian syndrome (PCOS) or disease (PCOD)
      • Polycystic ovarian disease  – Stein-Leventhal syndrome
      • Amongst infertile women, about 20% is attributed to anovulation caused by PCOS.
      • PCOS in earlier years lead to later in life (MCQ)
        • cardiovascular disease
        • hypertension,
        • endometrial cancer
        • type 2 diabetes
      • Aetiology and pathogenesis
        • insulin resistance is central key point in the genesis of PCOS.
        • Insulin induces LH to cause thecal hyperplasia and secrete androgens, testosterone and epiandrostenedione (MCQ)
        • Epiandrostenedione is converted in the peripheral fat to oestrone.
        • This leads to rise in the oestrogen and inhibin level. (MCQ)
        • These in turn cause high LH surge(MCQ)
        • Whereas oestrone level increases, oestradiol level remains normal with the result oestrone/oestradiol ratio rises. (MCQ)
        • Hyperandrogenism lowers the level of hepatic sex homone binding globulin (SHBG), (MCQ)
        • level of free testosterone rises leading to hirsutism. (MCQ)
        • Androgen
          • suppresses growth of the dominant follicle
          • prevents apoptosis of smaller follicles which are normally destined to disappear in the late follicular phase.
      • Associated with Syndrome X (MCQ)
        • diabetes, hypertension
        • hyperlipidaemia and cardiovascular disease
      • Endocrinological changes in PCOD:
        • Oestrone/E2 level rises. (MCQ)
        • LH level is raised over 10 IU/ml.
        • FSH level remains normal(MCQ)
        • FSH/LH ratio falls. (MCQ)
        • SHBG level falls due to hyperandrogenism.
        • Testosterone and epiandrostenedione levels rise.
        • Testosterone >2ng/ml
        • Free T >2.2pg/ml (Normal level 0.2-0.8 ng/ml)
        • Normal androstenedione level is 1.3-1.5 ng/ml.
        • DHEA > 700 ng/ml suggests adrenal tumour. (MCQ)
        • Prolactin is mildly raised in 15% cases.
        • Fasting insulin is more than 10 mIU/1 in PCOS.
        • Thyroid function tests may be abnormal (hypothyroidism).
        • 17 alpha-hydroxyprogesterone in the follicular phase > 300 ng/dl suggests adrenal hyperplasia due to 21 hydroxylase deficiency. (MCQ)
      • Clinical features(MCQ)
        • Young woman
        • Central obesity
        • BMI >30 kg/cm2
        • Waist line >35
        • Waist  over  hip ratio > 0.72 is abnormal.
        • Oligomenorrhoea, amenorrhoea
        • Infertility (20%)
        • Hirsutism
        • Acanthosis nigricans due to insulin resistance.
        • Thick pigmented skin over the nape of neck, inner thigh and axilla
        • For the diagnosis of PCOS, Rotterdam criteria (2003) suggest that at least two out of three criteria should be present. (MCQ)
          • Oligo/amenorrhoea, anovulation, infertility
          • Hirsutism
          • Ultrasound findings
      • Investigations
        • Ultrasound is diagnostic of PCOS.
          • The enlarged ovaries, their size and increased stroma. (MCQ)
          • Twelve or more small follicles each of 2-9 mm in size placed peripherally. (MCQ)
          • It rules out ovarian tumour.
          • It shows endometrial hyperplasia if present.
          • In case of doubt, abdominal scan will reveal adrenal hyperplasia or tumour.
          • Ultrasound should preferably be performed in the early follicular phase.
      • Laparoscopy is reserved for therapeutic purpose, now that the diagnosis can be based on ultrasound findings.
    • Treatment
      • Weight loss.
        • Weight loss of more than 5% of previous weight, alone is beneficial in mild hirsutism and it restores the hormonal milieu considerably. (MCQ)
      • Cigarette smoking should be abandoned.
        • It lowers E2 level and raises DHEA and androgen level.
      • Hormones to control menstruation are:
        • Oral combined pills (OC)
        • OC and cyproterone acetate.
      • Oestrogen
        • suppresses androgens and adrenal hormones (DHEA).
        • raises the secretion of SHBG in the liver, which binds with testosterone, thus reduces free testosterone. (MCQ)
        • suppresses LH. (MCQ)
        • best given as low-dose combined pills, having progestogen with lesser androgenic effect.
        • Fourth generation of combined pills which contains 30 microgms of E2 and 2-3 mg drospirenone (progestogen with anti-androgenic action) is best for PCOS (Yasmin, Janya, Tarana). (MCQ)
          • It helps to reduce acne and further development of hirsutism.
      • Progestogen(MCQ)
        • required to induce menstruation in amenorrhoeic woman prior to initiating hormonal cyclical therapy.
      • OC with cyproterone is prescribed if the woman has hirsutism.
      • Hirsutism.
        • Anti-androgens (MCQ)
        • managed by clindamycin lotion 1% or erythromycin gel 2% if pustules form. (MCQ)
        • For severe acne, isotretinoin is used(MCQ)
          • it is teratogenic and pregnancy should be avoided
        • Dexamethasone (0.5 mg) at bedtime (MCQ)
          • reduces androgen production
          • used in some infertile women with clomiphene.
      • Infertility.
        • Clomiphene (MCQ)
          • first line of treatment if PCOS woman is to be treated for infertility. (MCQ)
          • induces ovulation in 80% and 40-50% conceive, but 25-40% abortion rate is caused by corpus luteal phase defect.
          • Hyperstimulation occurs in 10% cases.
          • Clomiphene with dexamethasone improves fertility rate.
        • In a resistant case,
          • tamoxifen (MCQ)
          • off-label letrozole (MCQ)
          • Failure to above therapy calls for FSH, LH or GnRH analogues.
        • A woman with insulin resistance
          • requires metformin in addition. (MCQ)
          • This woman also shows raised level of homocysteine in which case N-acetyl-cysteine 1.2 g may be added to clo-miphene therapy.
            • N-acetyl-cysteine (NAC) is a mucolytic drug and insulin-sensitizer.
      • Metformin
        • treats the root cause of PCOS
        • rectifies endocrine and metabolic functions
        • improves fertility rate
        • is used as insulin sensitizer.
        • It reduces insulin level
        • delays glucose absorption
        • decreases liver neoglycolysis
        • improves peripheral utilization of glucose.
        • Liver function tests should be performed prior to metformin administration.
        • reduces the level of total and free testosterone
        • increases the sex hormone binding globulin.
        • Ovulation occurs in 70-80%, and pregnancy in 30-40%.
        • It does not cause hypoglycaemia
        • does not reduce weight.
        • It is contraindicated in hepatic and renal disease.
        • It causes gastrointestinal disturbances and lactic acidosis.
        • If metformin is contraindicated, acarbose 300 mg daily can replace it.
      • Octreotide (MCQ)
        • a peptide hormone secreted by hypothalamus
        • inhibits growth hormone and insulin.
        • enhances ovulation in clomiphene-resistant infertility.
    • Surgery
      • Surgery is reserved for those in whom (MCQ)
        • Medical therapy fails
        • Hyperstimulation occurs
        • Infertile women
        • Previous pregnancy losses.
      • Surgery comprises laparoscopic drilling or puncture of not more than four cysts in each ovary either by laser or by unipolar electrocautery.
      • Surgery restores endocrine milieu and improves fertility for a year or so. Thereafter, pelvic adhesions caused by surgery may again reduce fertility rate.
      • Hydrofloatation reduces adhesion formation.
      • Advantages of surgery are as follows: (MCQ)
        • Tubal testing with chromotubation can be performed simultaneously.
        • Other causes of infertility, i.e. endometriosis looked for.
        • One-time treatment.
        • Intense and prolonged monitoring not required.
        • Cost effective compared to IVF.
        • Reduces androgen and LH production
        • Following surgery, single ovulation occurs with drugs, and  hyperstimulation  and  multiple  pregnancy are avoided.
        • Ovulation occurs in 80-90% and pregnancy in 60-70%.
      • Disadvantages of surgery are as follows:
        • Adhesions may form postoperatively.
        • Premature ovarian failure due to destruction of ovarian tissue if cautery is used.
        • For this reason, many now prefer simple puncture of the cysts.

    Laparoscopy, Polycystic Ovarian Syndrome, PCOS, PCOD
    Polycystic Ovarian Syndrome
    Primary Infertility
    Operation was carried out on 8th April 2011
    Ovarian Drilling
    Patient was successfully pregnant within six months of operation.
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