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.

01:28 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 Today, we’ll discuss the management of polycystic ovary syndrome (PCOS) tailored to whether the patient is pursuing pregnancy or not. PCOS is a complex condition requiring a targeted approach to address symptoms, metabolic risks, and fertility concerns.

02:43 For Management in Women Not Pursuing Pregnancy: For women with oligomenorrhea or chronic anovulation, Combined Oral Contraceptives (COCs) are the first-line treatment.

02:56 COCs prevent endometrial hyperplasia and provide contraception.

03:01 If COCs are contraindicated, intermittent progestin therapy is an alternative option.

03:08 Hyperandrogenic symptoms like hirsutism, acne, and hair loss are managed with COCs containing lower-androgenicity progestins (e.g., norethindrone).

03:20 If COC monotherapy is not sufficient after six months, spironolactone, an antiandrogen, can be added.

03:28 However, spironolactone should be avoided during pregnancy due to risks to male fetal development.

03:35 Hair removal methods, like laser or electrolysis, are also effective for managing idiopathic hirsutism.

03:43 For obesity, glucose intolerance, and dyslipidemia, a combined approach is used: Diet and Exercise are recommended for patients with BMI > 25, with a goal of achieving a sustained 5–10% weight loss to improve insulin sensitivity and lower androgen levels.

04:05 Metformin + GLP-1 Receptor Agonists are effective for managing obesity and elevated glucose.

04:12 GLP-1 agonists also support weight loss and improve glucose control.

04:19 For those with established type 2 diabetes or dyslipidemia, additional treatments are necessary.

04:26 For the Management in Women Pursuing Pregnancy In Anovulatory Infertility, weight loss is the recommended first for women with obesity, as it may help restore ovulatory cycles. This lifestyle intervention can improve overall metabolic health and increase the chance of natural ovulation.

04:46 If lifestyle modifications alone are insufficient, ovulation induction is necessary.

04:52 Letrozole, an aromatase Inhibitor, is the preferred first-line agent for ovulation induction in PCOS, though it is used off-label for this purpose.

05:04 Clomiphene Citrate, a selective Estrogen Receptor Modulator, serves as an alternative if letrozole is not effective or suitable.

05:14 Key Takeaways to remember are that management of PCOS involves treating individual symptoms and risks based on the patient’s goals.

05:23 For women not pursuing pregnancy, focus on menstrual regulation, managing hyperandrogenism, and addressing metabolic health.

05:33 For those seeking pregnancy, lifestyle changes and ovulation induction agents like letrozole are essential.

05:40 This structured approach allows us to address the multifaceted nature of PCOS in a way that meets each patient's unique needs.