eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility

Polycystic Ovarian Syndrome

Author: Mukhtar I Khan, MD, Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, SUNY Upstate Medical University, Syracuse, NY
Contributor Information and Disclosures

Updated: Sep 4, 2009

Introduction

Background

Stein and Leventhal were the first to recognize an association between the presence of polycystic ovaries and signs of hirsutism and amenorrhea (eg, oligomenorrhea, obesity).1 After women diagnosed with Stein-Leventhal syndrome underwent successful wedge resection of the ovaries, their menstrual cycles became regular, and they were able to conceive.2 As a consequence, a primary ovarian defect was thought to be the main culprit, and the disorder came to be known as polycystic ovarian disease. Further biochemical, clinical, and endocrinologic studies revealed an array of underlying abnormalities; hence, the condition is now referred to as polycystic ovary syndrome (PCOS), though it may occur in women without ovarian cysts.

Pathophysiology

Women with PCOS have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. High serum concentrations of androgenic hormones, such as testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), may be encountered in these patients. However, individual variation is considerable, and a particular patient might have normal androgen levels.

PCOS is also associated with peripheral insulin resistance and hyperinsulinemia, and obesity amplifies the degree of both abnormalities. Insulin resistance in PCOS can be secondary to a postbinding defect in insulin receptor signaling pathways, and elevated insulin levels may have gonadotropin-augmenting effects on ovarian function.

In addition, insulin resistance in PCOS has been associated with adiponectin—a hormone secreted by adipocytes that regulates lipid metabolism and glucose levels; both lean and obese women with PCOS have lower adiponectin levels than women without PCOS.3

A proposed mechanism for anovulation and elevated androgen levels suggests that, under the increased stimulatory effect of luteinizing hormone (LH) secreted by the anterior pituitary, stimulation of the ovarian theca cells is increased. In turn, these cells increase the production of androgens (eg, testosterone, androstenedione). Because of a decreased level of follicle-stimulating hormone (FSH) relative to LH, the ovarian granulosa cells cannot aromatize the androgens to estrogens, which leads to decreased estrogen levels and consequent anovulation. Growth hormone (GH) and insulin-like growth factor–1 (IGF-1) may also augment the effect on ovarian function.4

Hyperinsulinemia is also responsible for dyslipidemia and for elevated levels of plasminogen activator inhibitor-1 (PAI-1) in patients with PCOS. Elevated PAI-1 levels are a risk factor for intravascular thrombosis.

Polycystic ovaries are enlarged bilaterally and have a smooth thickened capsule that is avascular. On cut sections, subcapsular follicles in various stages of atresia are seen in the peripheral part of the ovary. The most striking ovarian feature of PCOS is hyperplasia of the theca stromal cells surrounding arrested follicles. On microscopic examination, luteinized theca cells are seen.

Frequency

United States

PCOS is one of the most common endocrine disorders of women in the reproductive age group, with a prevalence of 4-12%.5,6

International

In various European studies, the prevalence of PCOS was 6.5-8%.7,8

Age

PCOS affects mostly women of reproductive age.

Clinical

History

Patients with PCOS may present with various clinical features.

  • Menstrual abnormalities
    • Patients have abnormal menstruation patterns attributed to chronic anovulation.
    • Some women have oligomenorrhea (ie, menstrual bleeding that occurs at intervals of 35 d to 6 mo, with <9 menstrual periods per y) or secondary amenorrhea (an absence of menstrual for 6 mo). Dysfunctional uterine bleeding and infertility are the other consequences of anovulatory menstrual cycles.
    • The menstrual irregularities in PCOS usually manifest around the time of menarche.
  • Hyperandrogenism
    • Hyperandrogenism clinically manifests as excess terminal body hair in a male distribution pattern. Hair is commonly seen on the upper lip, chin, around the nipples, and along the linea alba of the lower abdomen.
    • Some patients have acne and/or male-pattern hair loss (androgenic alopecia).
    • A few patients may also have increased muscle mass, deepening voice, and/or clitoromegaly due to excessive androgens.
  • Infertility
    • A subset of women with PCOS are infertile.
    • Most women with PCOS ovulate intermittently. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned.
  • Obesity
    • Obesity is present in nearly half of all women with PCOS.
    • A study comparing the body mass index (BMI) in American and Italian women with PCOS showed that American women had a BMI higher than that of their Italian counterparts.9
  • Diabetes mellitus: Approximately 10% of women with PCOS have type 2 diabetes mellitus, and 30-40% of women with PCOS have impaired glucose tolerance by the age of 40 years.10,11
  • Sleep apnea: Many women with PCOS have obstructive sleep apnea syndrome. These patients have excessive daytime somnolence and have apnea/hypopnea episodes during sleep.12,13
  • Acanthosis nigricans: Patients with PCOS may have dark, pigmented skin on the nape of their neck, skin folds, knuckles, and/or on elbows.
  • Metabolic syndrome
    • In women, metabolic syndrome is characterized by abdominal obesity (waist circumference > 35 in.), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] level < 50 mg/dL), elevated blood pressure, a proinflammatory state characterized by an elevated C-reactive protein level, and a prothrombotic state characterized by elevated PAI-1 and fibrinogen levels.14
    • Numerous patients with PCOS have characteristics of metabolic syndrome. One study showed a 43% prevalence of metabolic syndrome in women with PCOS.14
    • Women with PCOS have increased prevalence of coronary artery calcification and a thickened carotid intima media, which may be responsible for subclinical atherosclerosis.

Physical

Physical examination findings are notable for the findings described below.

  • Hirsutism: Patients may have excessive body hair in a male distribution pattern and acne. Some patients have virilizing signs, such as male-pattern balding or alopecia, increased muscle mass, deepening voice, or clitoromegaly; these findings should prompt a search for other causes of hyperandrogenism.
  • Obesity: Approximately 50% of women with PCOS have abdominal obesity characterized by a waist circumference of greater than 35 in (>88 cm).
  • Acanthosis nigricans: This is a diffuse, velvety thickening and hyperpigmentation of the skin. It may be present at the nape of the neck, axillae, area beneath the breasts, intertriginous areas, and exposed areas (eg, elbows, knuckles). In patients with PCOS, acanthosis nigricans is thought to be the result of insulin resistance.
  • Blood pressure: Patients with signs and symptoms of metabolic syndrome may have elevated blood pressure with a systolic blood pressure of 130 mm Hg or higher and diastolic blood pressure of 85 mm of Hg or higher.

More on Polycystic Ovarian Syndrome

Overview: Polycystic Ovarian Syndrome
Differential Diagnoses & Workup: Polycystic Ovarian Syndrome
Treatment & Medication: Polycystic Ovarian Syndrome
Follow-up: Polycystic Ovarian Syndrome
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Mukhtar I Khan, MD, Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, SUNY Upstate Medical University, Syracuse, NY
Disclosure: Nothing to disclose.

Medical Editor

Jordan G Pritzker, MD, MBA, FACOG, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital, Mammoth Lakes, California, Pioneer Valley Hospital, Salt Lake City, Utah, Warren General Hospital, Warren, Pennsylvania and Mountain West Hospital, Tooele, Utah
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Bryan D Cowan, MD, Professor and Chairman, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Veterans Affairs Medical Center; Medical Director, Wiser Hospital for Women, University of Mississippi Medical Center
Bryan D Cowan, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Endocrine Society, Sigma Xi, Society for Assisted Reproductive Technologies, Society for Gynecologic Investigation, Society for the Study of Reproduction, and Society of Laparoendoscopic Surgeons
Disclosure: Wyeth None Speaking and teaching

 
 
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