Polycystic Ovary Syndrome: Characteristics and Clinical Controversies

Polycystic Ovarian Syndrome (PCOS) Overview: 

• PCOS is a complex endocrine disorder affecting women of childbearing age characterized by increased androgen production and ovulatory dysfunction
• PCOS is the leading cause of anovulatory infertility and hirsutism
• Women with PCOS have an increased risk of miscarriage, insulin resistance, hyperlipidemia, type 2 diabetes, cardiovascular disease, and endometrial cancer

PCOS: National Institutes of Health Diagnostic Criteria 

• Presence of ovulatory dysfunction, polymenorrhea, oligomenorrhea, or amenorrhea

Clinical evidence of hyperandrogenism and/or hyperandrogenemia

• Exclusion of other endocrinopathies (eg, Cushing syndrome, hypothyroidism, late-onset congenital adrenal hyperplasia
• May appear at puberty with a delayed menarche followed by the onset of irregular periods or as the breakdown of a previously regular cycle 
• Anovulation is usually chronic and presents as oligomenorrhea or amenorrhea 

Clinical Features of PCOS - Hyperandrogenism

• Symptoms may include hirsutism, acne, male pattern balding, and/or male distribution of body hair
• Common Endocrine Abnormalities in PCOS
• Elevated luteinizing hormone (LH)
• Increased LH/follicle-stimulating hormone (FSH) ratio
• Elevated androgen levels
• Decreased sex hormone binding globulin levels 

Metabolic Abnormalities in PCOS

• Hyperinsulinemia and insulin resistance
• Insulin resistance may be independent of the effect of obesity
• Decreased peripheral insulin sensitivity and consequent hyperinsulinemia may play an important role in the pathogenesis of PCOS

Lipid and Lipoprotein Abnormalities in PCOS

• Elevated LDL cholesterol
• Elevated triglycerides 
• Decreased HDL cholesterol
• Decreased apolipoprotein A-I
• Impaired fibrinolytic activity

Etiology of PCOS

PCOS may be caused by interactions between

• Genetic factors (eg, autosomal dominant transmission)
• Endocrine factors (eg, increased LH/FSH ratio, increased insulin and androgen concentrations)
• Metabolic factors (eg, increased insulin resistance,  decreased SHBG)
• Neurologic factors (eg, epileptic discharges)
• Environmental factors (eg, anabolic steroids) 

Developmental Origin of PCOS

During gestation, human chorionic gonadotrophin, LH, and genes regulating folliculogenesis and steroidogenesis may cause excess prenatal androgen

Postpubertally, hyperinsulinemia and LH hypersecretion augment ovarian steroidogenesis, leading to anovulation.

by

Akshaya Srikanth,

Pharm.D Internee,

Hyderabad, India