Polycystic Ovary Syndrome

Polycystic Ovary Syndrome - Ovary's Uproar

• Common endocrine disorder affecting 5-10% of reproductive-age women.
• Diagnosis via Rotterdam criteria (need ≥2 of 3):
  • Oligo-ovulation or anovulation (e.g., irregular menses).
  • Clinical (hirsutism, acne) and/or biochemical (↑testosterone) signs of hyperandrogenism.
  • Polycystic ovarian morphology (PCOM) on ultrasound: ≥12 follicles (2-9mm diameter) in at least one ovary, or ovarian volume >10ml.
• Strongly associated with insulin resistance.

⭐ An elevated LH/FSH ratio (often >2:1) is a characteristic finding, but it is NOT part of the Rotterdam diagnostic criteria for PCOS.

Polycystic Ovary Syndrome - Insulin's Ire

• Core: Peripheral Insulin Resistance (IR) leads to compensatory Hyperinsulinemia.
• Pathophysiology:
  • Ovaries: Hyperinsulinemia directly stimulates ovarian theca cells → ↑Androgen (testosterone, androstenedione) production.
  • Liver: Insulin suppresses Sex Hormone Binding Globulin (SHBG) synthesis → ↑Bioavailable free androgens.
  • Pituitary: Altered GnRH pulsatility favors LH over FSH → ↑LH/FSH ratio (often >2:1, classically >3:1).
• Key Results: Chronic anovulation (menstrual irregularity), hyperandrogenism (hirsutism, acne, alopecia).
• Long-term Risks: ↑Type 2 Diabetes, dyslipidemia, endometrial hyperplasia, cardiovascular disease.

⭐ Acanthosis nigricans, a velvety hyperpigmentation often seen in skin folds (neck, axillae), is a common cutaneous marker of insulin resistance in PCOS.

Polycystic Ovary Syndrome - Hirsute & Cycles

• Menstrual Dysfunction:
  • Oligomenorrhea (<9 cycles/year or cycle length >35 days) or amenorrhea (no menses for ≥3 months).
  • Chronic anovulation often leading to infertility.
• Hyperandrogenism (Clinical/Biochemical):
  • Hirsutism: Terminal hair in male pattern (Modified Ferriman-Gallwey score ≥8).
    • Common sites: Upper lip, chin, chest, back.
  • Acne vulgaris (persistent, adult-onset).
  • Androgenic alopecia (male-pattern baldness).
  • ↑ Serum testosterone (total or free).

⭐ Rotterdam criteria (requires 2 of 3): oligo- and/or anovulation, clinical and/or biochemical signs of hyperandrogenism, polycystic ovaries on ultrasound (PCOM).

Polycystic Ovary Syndrome - The Rotterdam Rule

Diagnosis requires 2 of 3 criteria (Rotterdam criteria):

• Oligo- and/or anovulation
• Clinical and/or biochemical signs of hyperandrogenism
• Polycystic ovaries on ultrasound (PCOM):
  • ≥12 follicles (2-9 mm) in each ovary OR
  • Ovarian volume >10 mL

Exclude other etiologies (e.g., congenital adrenal hyperplasia, androgen-secreting tumors, Cushing's syndrome).

⭐ Hirsutism is the most common clinical sign of hyperandrogenism in PCOS.

Key Investigations: Serum testosterone, SHBG, DHEAS, 17-OHP, TSH, prolactin, OGTT, lipid profile. Consider transvaginal ultrasound (TVS).

Polycystic Ovary Syndrome - Managing Mayhem

• Key Goals: Restore fertility, manage hyperandrogenism & metabolic issues, prevent endometrial hyperplasia.
• Letrozole: Preferred over clomiphene for ovulation induction (↑ live birth rates).

  ⭐ PCOS ↑ endometrial cancer risk 2-6x due to chronic anovulation & unopposed estrogen.

High‑Yield Points - ⚡ Biggest Takeaways

• Rotterdam criteria (2/3: oligo/anovulation, hyperandrogenism, PCOM on USG) for diagnosis.
• Insulin resistance & hyperinsulinemia are core pathophysiological drivers.
• High risk for metabolic syndrome, T2DM, dyslipidemia, CVD.
• ↑ LH:FSH ratio (often >2:1) is a supportive finding.
• First-line for anovulatory infertility: letrozole. Hirsutism: OCPs, spironolactone.
• Chronic anovulation ↑ risk of endometrial hyperplasia & cancer.
• Weight loss is a key management strategy in overweight/obese individuals.