A 20-year old average weight female complains of oligomenorrhea along with facial hair. Preliminary investigations reveal raised free testosterone levels. USG Pelvis: ovary shows "subcapsular cysts" of varying size. Which of the following could be likely etiology?
Ans. b. PCOD (Ref: Jeffcott 6/e p205; Shaw's 14/331-332, 13/e p353-354; Novaks 14/1077, 1082) Most likely etiology in a 20-year old average weight female with complains of oligomenorrhea and facial hair with raised free testosterone levels and normal morphology of ovaries on ultrasound is PCOD. Drug not given in PCOD in a 30-year-old lady with infertility is tamoxifen. Polycystic Ovarian Syndrome/Stein Levinthal's Syndrome Diagnostic Criteria for PCOS Major Minor * Chronic anovulationQ * HyperandrogenemiaQ * Clinical signs of hyperandrogenemiaQ * Other etiologies excludedQ * Insulin resistanceQ * Perimenarchal onset of hirsutism and obesityQ * Elevated LH to FSH ratioQ * Intermittent anovulation with hyperandrogenemiaQ Clinical Features: Seen mostly in 15-25 years of ageQ It includes chronic non-ovulation and hyperandrogenemia associated with normal or raised estrogen (E2), raised LH, low FSH/LH ratio.Q The raised E2 level causes negative feedback to pituitary resulting in diminished FSH, but raised LHQ. The involvement of the adrenal gland is seen in raised androstenedione, dehydroepiandrosterone, testosterone and 17 alpha-hydroxyprogesterone. Much of the testosterone is secreted by the ovarian stromaQ Appearance: Macroseopically, the ovaries are often bilaterally enlarged, with thick capsuled The surface may be lobulated but the peritoneal surface is free from adhesions. Multiple cyst 0.5 to 1 mm and at times up to 20 mm in size are localized along the surface of the ovary giving a "necklace" appearance on ultrasoundQ. Theca cell hyperplasia is seen which produces excess testosterone secretion. Ultrasound shows several "subcapsular cysts" of varying size, diagnostic of PCOSQ. Laparoscopic evaluation is not only diagnostic, but also therapeuticQ. Treatment: Weight lossQ of more than 5% of previous weight is important. Cigarette smoking should be avoidedQ Estrogen best given with progesterone with no androgenic properties. Dexamethasone 0.5 mg at bedtime also reduces androgen production. Hirsutism is treated with cyproterone acetate or spironolactone. Infertility is treated with Clomiphene, 80% ovulate and 40% conceive. However, abortion rate of 25-40% is due to corpus luteal phase defect manifested by ClomipheneQ. In Clomiphene failed group, ovulation can be induced with FSH or GnRH analoguesQ Metformin treats the root cause of PCOSQ, rectifies endocrine and metabolic functions and improves fertility and is drug of choiceQ. Surgery (laparoscopic multiple puncture of cyst) is reserved for those in whom: Medical therapy fails Hyperstimulation occurs Use of GnRH analogue is a cost constraint Consequences of Polycystic Ovarian Syndrome Short-Term Consequences Long-Term Consequences * Menstrual dysfunctionQ (Irregular menses): - Amenorrhea. Oligomenorrhea - Episodic menomectorrhagia * Hyperandrogen ismQ: - HirsutismA, Acne, Androgenic alopecia * InfertilityQ * ObesityQ * Insulin resistanceQ (Acanthosis nigricans) * Dyslipidemia0 (Androgenic lipoprotein profile): - Increased LDL and TG - Increased Total cholesterol: HDL ratio - Decreased HDL * Metabolic syndromeQ: Characterized by insulin resistance,obesity, androgenic dyslipidemia and hypertension * Obstructive sleep apneaQ (Related to central obesity and dyslipidemia) * Diabetes mellitusQ: increased risk of impaired glucose tolerance and type 2 DM in PCOS patients * Cardiovascular diseasesQ: Greater prevalence of atherosclerosis and cardiovascular disease with an increased risk of myocardial infarction * Cancer: * Endometrial carcinomaQ (3 fold increase risk) * Ovarian cancerQ - Women with PCOS are associated with a definite increased risk of endometrial cancer. An increased risk of ovarian cancer and breast cancer has also been suggested.
Idiopathic hirsutism
PCOD
Adrenal hyperplasia
Testosterone secreting tumor
Disorders in Menstruation