Polycystic ovary syndrome: Difference between revisions
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* [[Androgen-dependent syndromes]] |
* [[Androgen-dependent syndromes]] |
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* ''[[PCOS Challenge]]'' (reality television series) |
* ''[[PCOS Challenge]]'' (reality television series) |
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* [http://www.ThePCOSClinic.com The PCOS Clinic - Free PCOS Weight Loss and Fertility Information] |
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== References == |
== References == |
Revision as of 04:16, 16 December 2012
Polycystic ovary syndrome | |
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Specialty | Endocrinology, gynaecology |
Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of uncertain etiology, but there is strong evidence that it can to a large degree be classified as a genetic disease.[1][2][3]
PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (12–45 years old). It is thought to be one of the leading causes of female subfertility[4][5][6] and the most frequent endocrine problem in women of reproductive age.[7]
The principal features are anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries; excessive amounts or effects of androgenic hormones, resulting in acne and hirsutism; and insulin resistance, often associated with obesity, Type 2 diabetes, and high cholesterol levels.[8] The symptoms and severity of the syndrome vary greatly among affected women.
Classification
The World Health Organization criteria for classification of anovulation include the determination of oligomenorrhea (menstrual cycle >35 days) or amenorrhea (menstrual cycle > 6 months) in combination with concentration of prolactin, follicle stimulating hormone (FSH) and estradiol. Almost 80% of anovulation patients have normal serum FSH and estradiol levels and demonstrate very heterogeneous symptoms ranging from anovulation, obesity, biochemical or clinical hyperandrogenism and insulin resistance. PCOS is the most common cause of anovulation in women with normal serum FSH and estradiol levels.[9] Despite the heterogeneity in symptoms associated with PCOS, the essential feature is arrested follicular development at the stage when selection of the dominant follicle should normally occur.[10] The small ovarian follicles are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – essentially a cyst that bursts to release the egg. After ovulation the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so-called "follicular arrest", i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more).
Signs and symptoms
PCOS includes a heterogeneous collection of signs and symptoms with varying degree of mildness and severity in affecting the reproductive, endocrine and metabolic functions.[11] The classic triad of the disorder includes hirsutism, menstrual dysfunction, and obesity. Some common symptoms of PCOS include:
- Menstrual disorders: PCOS mostly produces oligomenorrhea or amenorrhea, but other types of menstrual disorders may also occur.[7][12]
- Infertility:[12] This generally results directly from chronic anovulation (lack of ovulation).[7]
- Hyperandrogenism: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods) or other symptoms.[7][13] Approximately three-quarters of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.[14]
- Metabolic syndrome:[12] This appears as a tendency towards central obesity and other symptoms associated with insulin resistance.[7] Serum insulin, insulin resistance and homocysteine levels are higher in women with PCOS.[15]
Symptom | Frequency |
---|---|
Oligomenorrea | 29-52% |
Amenorrea | 19-51% |
Hirsutism | 64-69% |
Obesity | 35-41% |
Acne | 27-35% |
Alopecia | 3-6% |
Acanthosis nigricans | <1-3% |
Infertility | 20-74% |
Elevated Serum LH | 40-51% |
Elevated testosterone | 29-50% |
Diagnosis
In 1990, a consensus workshop sponsored by the NIH/NICHD suggested that a patient has PCOS if she has all of the following:[17]
- oligoovulation
- signs of androgen excess (clinical or biochemical). Androgen excess can be tested by measuring total and free testosterone levels. Other androgens, such as DHEA-S, may be normal or slightly above the normal range in patients with polycystic ovarian syndrome (PCOS) while levels of sex hormone–binding globulin (SHBG) are usually low in patients with PCOS. Androstenedione levels are also elevated in women with PCOS. This androgen precursor is 60% ovarian and 40% adrenal in derivation.[18]
- other entities are excluded that would cause polycystic ovaries
More recently, in 2003, a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if any 2 out of the following 3 criteria are met and other entities are excluded that would cause these.[7][19] [20]
- oligoovulation and/or anovulation
- excess androgen activity
- polycystic ovaries (by gynecologic ultrasound). According to available literature, at least one of the following criteria should be present to establish polycystic ovaries: either 12 or more follicles measuring 2–9 mm in diameter, or increased ovarian volume (>10 cm3).[21] Not all women with PCOS have polycystic ovaries (PCO), nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one.[22]
The initial NIH diagnostic criteria based on oligomenorrhoea/amenorrhoea and clinical or biochemical hyperandrogenism have been broadened in the 2003 Rotterdam diagnostic criteria to include polycystic ovaries (PCO) at ultrasound as a key diagnostic criteria. A total of 25% of young women have PCO on ultrasound and the inclusion of PCO in diagnostic criteria has increased the prevalence of PCOS. Earlier studies conducted in Greece, Spain and USA using the NIH criteria estimated the prevalence of PCOS at 4% to 8%. However, the first community-based prevalence study based on current Rotterdam diagnostic criteria conducted recently has shown the prevalence of PCOS to be 18%.[7] The Rotterdam definition is wider, including many more patients, most notably patients without androgen excess. Critics say that findings obtained from the study of patients with androgen excess cannot necessarily be extrapolated to patients without androgen excess.[23][24]
In 2006, the Androgen Excess & PCOS Society suggested a tightening of the diagnostic criteria to all of:[7]
- excess androgen activity
- oligoovulation/anovulation and/or polycystic ovaries
- other entities are excluded that would cause excess androgen activity
A recent study found that a questionnaire addressing the history of menstrual pattern, obesity and hirsutism can diagnose PCOS, according to a clinical prediction rule, with a sensitivity of 77.1% (95% confidence interval [CI] 62.7%–88.0%) and a specificity of 93.8% (95% CI 82.8%–98.7%).[25] Some other blood tests are suggestive but not diagnostic. The ratio of LH (luteinizing hormone) to FSH (follicle stimulating hormone), when measured in international units, is greater than 1:1 (sometimes more than 3:1),[18] as tested on Day 3 of the menstrual cycle. The pattern is not very specific and was present in less than 50% in one study.[26]
Common assessments for associated conditions or risks
- Fasting biochemical screen and lipid profile[18]
- 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity, family history, history of gestational diabetes)[7] may indicate impaired glucose tolerance (insulin resistance) in 15–33% of women with PCOS.[18] Frank diabetes can be seen in 65–68% of women with this condition.[citation needed] Insulin resistance can be observed in both normal weight and overweight patients, although it is more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of PCOS patients may have insulin resistance at some level.[7]
- Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women who will need higher dosages of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. A mathematical derivation known as the HOMAI, calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).[citation needed]
- Glucose tolerance testing (GTT) instead of fasting glucose can increase diagnosis of increased glucose tolerance and frank diabetes among patients with PCOS according to a prospective controlled trial.[27] While fasting glucose levels may remain within normal limits, oral glucose tests revealed that up to 38% of asymptomatic women with PCOS (versus 8.5% in the general population) actually had impaired glucose tolerance, 7.5% of those with frank diabetes according to ADA guidelines.[27]
Differential diagnosis
Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secreting neoplasms, and other pituitary or adrenal disorders, should be investigated.[7][18][19] PCOS has been reported in other insulin-resistant situations such as acromegaly.[citation needed]
Cause
PCOS is a complex, heterogeneous disorder of uncertain aetiology.[1][2][12] There is strong evidence that it is a genetic disease. Such evidence includes the familial clustering of cases, greater concordance in monozygotic compared with dizygotic twins and heritability of endocrine and metabolic features of PCOS.[1][2][3]
The genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance but variable expressivity in females; this means that each child has a 50% chance of inheriting the predisposing genetic variant(s) from a parent, and if a daughter receives the variant(s), then the daughter will have the disease to some extent.[2][28][29][30] The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early baldness and/or excessive hair) and daughters, who will show signs of PCOS.[28][30] The allele appears to manifest itself at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele.[29] The exact gene affected has not yet been identified.[2][3][31]
The clinical severity of PCOS symptoms appears to be largely determined by factors such as obesity.[3][7]
Pathogenesis
Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility[29]):
- the release of excessive luteinizing hormone (LH) by the anterior pituitary gland[citation needed]
- through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus[12]
Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens.[citation needed]
The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These "cysts" are actually immature follicles, not cysts ("polyfollicular ovary syndrome" would have been a more accurate name). The follicles have developed from primordial follicles, but the development has stopped ("arrested") at an early antral stage due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.[citation needed]
Women with PCOS have higher GnRH, which in turn results in an increase in LH/FSH ratio.[32]
A majority of patients with PCOS have insulin resistance and/or are obese. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production,[12] decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the development of PCOS.[citation needed] Insulin resistance is a common finding among patients of normal weight as well as overweight patients.[7][15]
In many cases PCOS is characterised by a complex positive feedback loop of insulin resistance and hyperandrogenism. In most cases it can not be determined which (if any) of those two should be regarded causative. Experimental treatment with either antiandrogens or insulin sensitizing agents improves both hyperandrogenism and insulin resistance.[citation needed]
Adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese patients creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and estrogens (which inhibits FSH via negative feedback).[33]
PCOS may be associated with chronic inflammation,[12][34] with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.[35][36]
It has previously been suggested that the excessive androgen production in PCOS could be caused by a decreased serum level of IGFBP-1, in turn increasing the level of free IGF-I which stimulates ovarian androgen production, but recent data concludes this mechanism to be unlikely.[37]
PCOS has also been associated with a specific FMR1 sub-genotype. The research suggests that women who have heterozygous-normal/low FMR1 have polycystic-like symptoms of excessive follicle-activity and hyperactive ovarian function.[38]
Management
Medical treatment of PCOS is tailored to the patient's goals. Broadly, these may be considered under four categories:
- Lowering of insulin levels
- Restoration of fertility
- Treatment of hirsutism or acne
- Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer
In each of these areas, there is considerable debate as to the optimal treatment. One of the major reasons for this is the lack of large scale clinical trials comparing different treatments. Smaller trials tend to be less reliable and hence may produce conflicting results.
General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause.
In addition, as PCOS appears to cause significant emotional distress, it is recommended that clinicians discuss emotional aspects of PCOS with patients and refer for appropriate support where necessary and in accordance with patient preference.[39]
Diet
Where PCOS is associated with overweight or obesity, successful weight loss is the most effective method of restoring normal ovulation/menstruation, but many women find it very difficult to achieve and sustain significant weight loss. Low-carbohydrate diets and sustained regular exercise[40] may help. Some experts recommend a low GI diet in which a significant part of total carbohydrates are obtained from fruit, vegetables and whole grain sources.[12][41] Vitamin D deficiency may play some role in the development of the metabolic syndrome,[40] so treatment of any such deficiency is indicated.
Medications
Reducing insulin resistance by improving insulin sensitivity through medications such as metformin, and the newer thiazolidinedione (glitazones), have been an obvious approach and initial studies seemed to show effectiveness.[12][40][42] Although metformin is not licensed for use in PCOS, the United Kingdom's National Institute for Health and Clinical Excellence recommended in 2004 that women with PCOS and a body mass index above 25 be given metformin when other therapy has failed to produce results.[43] However subsequent reviews in 2008 and 2009 have noted that randomised control trials have in general not shown the promise suggested by the early observational studies.[44][45]
Infertility
Not all women with PCOS have difficulty becoming pregnant. For those who do, anovulation or infrequent ovulation is a common cause. Other factors include changed levels of gonadotropins, hyperandrogenemia and hyperinsulinemia.[46] Like women without PCOS, women with PCOS who are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases.
For overweight, anovulatory women with PCOS, weight loss and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with resumption of natural ovulation.
For those who after weight loss still are anovulatory or for anovulatory lean women, then the ovulation-inducing medications clomiphene citrate[40] and FSH are the principal treatments used to promote ovulation.[12] Previously, the anti-diabetes medication metformin was recommended treatment for anovulation,[12] but it appears less effective than clomiphene.[47]
For patients who do not respond to clomiphene, diet and lifestyle modification, there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with follicle-stimulating hormone (FSH) injections followed by in vitro fertilisation (IVF).
Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (puncture of 4–10 small follicles with electrocautery, laser, or biopsy needles), which often results in either resumption of spontaneous ovulations[40] or ovulations after adjuvant treatment with clomiphene or FSH.[citation needed] (Ovarian wedge resection is no longer used as much due to complications such as adhesions and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function.[40]
Hirsutism and acne
When appropriate (e.g. in women of child-bearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism.[12][40] A common choice of contraceptive pill is one that contains cyproterone acetate; in the UK the available brands are Dianette/Diane. Cyproterone acetate is a progestogen with anti-androgen effects that block the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair.[citation needed] On the other hand, progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects.[40]
Other drugs with anti-androgen effects include flutamide[48] and spironolactone,[12][40] which can give some improvement in hirsutism. Spironolactone is probably the most-commonly used drug in the US. Metformin can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such as insulin resistance, diabetes or obesity that should also benefit from metformin. Eflornithine (Vaniqa) is a drug which is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is usually applied to the face.[40] Medications that reduce acne by indirect hormonal effects also include ergot dopamine agonists such as bromocriptine.[citation needed] 5-alpha reductase inhibitors (such as finasteride and dutasteride) may also be used;[49] they work by blocking the conversion of testosterone to dihydrotestosterone (the latter of which is responsible for most hair growth alterations and androgenic acne).
Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals[40]), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism, or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other drug treatments if one does not work, but drug treatments do not work well for all individuals. For removal of facial hairs, electrolysis or laser treatments are – at least for some – faster and more efficient alternatives than the above mentioned medical therapies.[citation needed]
Menstrual irregularity and endometrial hyperplasia
If fertility is not the primary aim, then menstruation can usually be regulated with a contraceptive pill.[12][40] The purpose of regulating menstruation is essentially for the woman's convenience, and perhaps her sense of well-being; there is no medical requirement for regular periods, so long as they occur sufficiently often (see below).[citation needed]
If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required – most experts consider that if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.[50] If menstruation occurs less often or not at all, some form of progestogen replacement is recommended.[49] Some women prefer a uterine progestogen device such as the intrauterine system (Mirena) or the progestin implant (Nexplanon), which provides simultaneous contraception and endometrial protection for years.[citation needed] An alternative is oral progestogen taken at intervals (e.g. every three months) to induce a predictable menstrual bleeding.[12]
Complementary or alternative approaches
At least two inositol isomers – D-chiro-inositol and myo-inositol have shown considerable promise in improving PCOS. They are generally very well tolerated and have been evaluated by several small-scale trials.[51][52][53] Inositol has no documented side-effects and is a naturally occurring human metabolite known to be involved in insulin metabolism.[54] DCI is regulated as a dietary supplement in the United States. Myo-inositol is naturally present in many foods although not readily digestible from most of them.[citation needed]
Prognosis
Women with PCOS are at risk for the following:
- Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by estrogen.[12][17] It is not clear if this risk is directly due to the syndrome or from the associated obesity, hyperinsulinemia, and hyperandrogenism.[55][56][57][58]
- Insulin resistance/Type II diabetes.[12] A review published in 2010 concluded that women with PCOS had an elevated prevalence of insulin resistance and type II diabetes, even when controlling for body mass index (BMI).[17][59] PCOS also makes a woman, particularly if obese, prone to gestational diabetes.[12]
- High blood pressure, particularly if obese and/or during pregnancy[12]
- Depression/Depression with anxiety[7][60]
- Dyslipidemia[12] – disorders of lipid metabolism — cholesterol and triglycerides. PCOS patients show decreased removal of atherosclerosis-inducing remnants, seemingly independent of insulin resistance/Type II diabetes.[61]
- Cardiovascular disease,[12][17] with a meta-analysis estimating a 2-fold risk of arterial disease for women with PCOS relative to women without PCOS, independent of BMI.[62]
- Strokes[17]
- Weight gain[12]
- Miscarriage[4][5]
- Sleep apnea, particularly if obesity is present[12]
- Non-alcoholic fatty liver disease, again particularly if obesity is present[12]
- Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck)[17]
- Autoimmune thyroiditis[63]
Early diagnosis and treatment may reduce the risk of some of these, such as type 2 diabetes and heart disease.[12]
Epidemiology
The prevalence of PCOS depends on the choice of diagnostic criteria. One community-based prevalence study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of them were previously undiagnosed.[7]
One study in the United Kingdom concluded that the risk of PCOS development was higher in lesbian women than in heterosexuals.[64] However, two subsequent studies of women with PCOS have not replicated this finding.[65][66]
History
The condition was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal, from whom its original name of Stein-Leventhal syndrome is taken.[17][22] Although Stein and Leventhal were the first in modern medicine to describe the condition, earlier references include the description by Vallisneri in 1721 of larger than normal ovaries and the description by Chereau in 1844 of sclerocystic changes in the ovaries.[67] Chereau's report was followed by observations of other European gynecologists in the second half of the nineteenth century. Stein and Leventhal's article identified the symptoms associated with the ovarian changes and reported wedging procedure as a highly successful remedial procedure. However, the simple symptoms for PCOS described by Stein and Leventhal could not last long, as the same symptoms were also found in patients diagnosed with other ovarian conditions like hyperthecosis and hilus cell tumors as well as in patients diagnosed with nonovarian hyperandrogenism of various types, such as adrenal hyperplasia and Cushing's syndrome. Polycystic ovaries were later found to exist in some women with subtle endocrine disorders. The wide range and frequency of symptoms made it difficult to establish a consistent clinical picture.[68]
Names
Other names for this syndrome include polycystic ovary disease, functional ovarian hyperandrogenism, ovarian hyperthecosis, sclerocystic ovary syndrome, and Stein-Leventhal syndrome. The eponymous last option is the original name; it is now used, if at all, only for the subset of patients with all the symptoms of amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries.[22]
Most common names for this disease derive from a typical finding on medical images, called a polycystic ovary.[12] A polycystic ovary has an abnormally large number of developing eggs visible near its surface,[22] looking like many small cysts[69] or a string of pearls.
See also
- Androgen-dependent syndromes
- PCOS Challenge (reality television series)
- The PCOS Clinic - Free PCOS Weight Loss and Fertility Information
References
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- ^ a b Boomsma CM, Fauser BC, Macklon NS (2008). "Pregnancy complications in women with polycystic ovary syndrome". Semin. Reprod. Med. 26 (1): 72–84. doi:10.1055/s-2007-992927. PMID 18181085.
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- ^ a b c d e f g h i j k l m n o p q r s t u v w x y z Mayo Clinic Staff (4 April 2011). "Polycystic Ovary Syndrome – All". MayoClinic.com. Mayo Clinic. Retrieved 15 November 2011.
- ^ Christine Cortet-Rudelli, Didier Dewailly (2006). "Diagnosis of Hyperandrogenism in Female Adolescents". Hyperandrogenism in Adolescent Girls. Armenian Health Network, Health.am. Retrieved 2006-11-21.
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