Polycystic Ovary Syndrome (PCOS): Clinical Presentation and Management

00:01 Polycystic ovarian syndrome is accompanied by insulin resistance.

00:05 Elevated insulin levels enhance ovarian and adrenal androgen production as well as increase the bioavailability of androgens which are related to a reduction in sex hormone binding globulin.

00:18 Polycystic ovary syndrome is associated with an increase incidence of the metabolic syndrome, prediabetes, type 2 diabetes, hypercholesterolemia and obesity.

00:30 Exposure to exogenous testosterone which may be topical, oral or injected can also be assessed as a possible cause of hyperandrogenism and virilization.

00:41 This particular case manifest clinically as patients whose partners are using topical testosterone replacements and whose skin comes into contact with them, usually at night when they lie together in bed and the testosterone cream then rubs off unto the female partner, causing hirsutism.

01:02 These patients should be worked up by having a total testosterone and sex hormone binding globulin measured.

01:09 Morning 17-hydroxyprogesterone should be done to screen for congenital adrenal hyperplasia.

01:15 Evaluation for oligomenorrhea or amenorrhea should be done by checking a HCG, a prolactin, an FSH, a TSH and a free thyroxine level.

01:27 Serum dihydroepiandosterone sulfate or DHEAs measurement is obtained in cases of recent onset or rapidly progressive hirsutism and/or virilization Mechanical hair removal to treat the hirsutism involves threading, depilatories, electrolysis and laser and may be adequate for most cosmesis in women with idiopathic hirsutism.

01:54 First line pharmacological management of hirsutism with the above findings, with the above treatments have not worked, is combined hormonal estrogen and progesterone oral contraceptive agents.

02:06 If the oral contraceptives do not work, antiandrogen therapy with spironolactone can often be added for better cosmetic response.

02:14 Please note to beware of prescribing spironolactone to females of reproductive age because this medication can be quite teratogenic.

02:23 The management of hyperandrogenism should primarily consist of weight loss as the first line intervention for patients with a BMI of 25 or greater.

02:33 Sustained weight loss of up to 5-10% will improve androgen levels, menstrual function and possibly fertility.

02:42 The oral contraceptive is a first line pharmacologic therapy for hirsutism and menstrual dysfunction unless fertility is desired.

02:50 If a fertility is required, clomiphene citrate or letrozole can be used to correct oligo- and anovulation.

02:59 Finally, metformin reduces hyperinsulinemia and androgen levels but it doesn't improve the hirsutism or the fertility.