Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in women. The prevalence varies between populations; it is approximately 15-18%. Clinical findings are variable...
Diagnostic Criteria and Phenotypes of Polycystic Ovary Syndrome
The most common symptoms of Polycystic Ovary Syndrome are as follows:
- Oligo/anovulation
- Hyperandrogenism (clinical/biochemical)
- Polycystic Ovary Morphology (PCOM)
Oligo/anovulation is defined as 35 or more days between two menstrual periods or 200 days (approximately 6 months) without menstruation.
Hyperandrogenism should be defined as the presence of hirsutism (male pattern hair growth), acne (acne formation), alopecia (male pattern hair loss) or elevated levels of the androgen hormones free testosterone (sT), dehydroepiandrosterone (DHEAS), and androstenedione (A4).
Hirsutism is the most common finding of clinical hyperandrogenism in PCOS. The diagnosis of hirsutism is made by scoring hair growth in nine different body regions according to the Ferriman-Gallway Scale. Scoring above 8% is considered as hirsutism.
Polycystic ovary morphology is defined as at least 12 follicles with a diameter of 2-9 mm arranged in a pearl-shaped arrangement in the ovarian cortex or an increased ovarian volume >10 ml (Figures 1 - 2).
Figure 1: Typical PCOS appearance with small follicles arranged like pearls in the cortex and increased hyperechogenous stroma.
Figure 2: 3D (three-dimensional) Polycystic Ovary Morphology on Ultrasonography
Today, Polycystic Ovary Syndrome is diagnosed with the presence of at least two of the findings of oligo/anovulation hyperandrogenism and polycystic ovarian morphology as recommended by NIH (United States National Institute of Health) and ASRM/ESHRE (American Society for Reproductive Medicine / European Society for Human Reproduction and Embryology).
Obesity, insulin resistance, hyperinsulinaemia, high LH levels and high LH/FSH ratio are also important findings that may accompany this syndrome.
Polikistik Over Sendromu tanısı düşündüğümüz hastalarda bu sendromun özelliklerini taklit eden başka hastalıkların ayrımını yapmak hastaya doğru yaklaşım ve doğru tedavi uygulamak açısından önemlidir. Ayırıcı tanıda dikkat edilmesi gereken hastalıklar ve ayrıca tanıda önemli tetkikler aşağıda gösterilmiştir.
Androgen secreting tumours
Testosterone > 200 ng/dl
DHEA-S >700 mcg/dl
HAIR-AN Syndrome
Basal fasting insulin >25 μIU/ml, 2nd hour OGTT >300 μIU/ml
Testosterone > 150 ng/dl
Cushing's Syndrome
Free cortisol in 24-hour urine (>300 μg)
Hypo/hyperthyroidism
TSH >4 mIU/L
Hyperprolactinaemia
Prolactin >24ng/mL
Non-classical Adrenal Hyperplasia
Basal serum 17-OHP (> 200 ng/dl)-ACTH stim test
The form showing ovarian morphology, oligo/anovulation and hyperandrogenemia parameters that we evaluate in the approach to the diagnosis of PCOS in our centre (Figure 3).
Figure 3: Parameters we evaluated in approach to diagnosis of PCOS.
Table 1. Phenotyping according to PCOS Diagnostic criteria
Infertility is a common presenting complaint for women with PCOS. Although the main cause of infertility seems to be oligo/anovulation, endometrial changes that prevent implantation and obesity are also factors that lead to infertility.
Women with polycystic ovary syndrome presenting with infertility require management of PCOS-related infertility if no other cause is found.
Management of PCOS-related Infertility
Lifestyle modification is the first-line treatment for both obese and lean women with PCOS. The combination of diet and exercise improves the hormonal profile, improves the response to assisted reproductive techniques and reduces the risk of complications during pregnancy.
Clomiphene citrate (CC) is the first-line pharmacological treatment for ovulation induction (ovarian stimulation phase). It is started between days 2-5 of the menstrual period. 5-day treatment is planned as 50mg/day starting dose.
Aromatase Inhibitors may be preferred as a first-line treatment option in case of clomiphene citrate failure or resistance. It is started between days 3-7 of the menstrual period. 5-day treatment is planned as an initial dose of 2.5mg/day.
Metformin is an insulin sensitiser and contributes to the improvement of PCOS symptoms. When started 3 months before fertility treatment and continued for 9 months after the start of treatment, it contributes to pregnancy and live birth rates.
Gonadotropins are used as second-line treatment in case of failure or resistance to clomiphene citrate. It is started between days 2-5 of the menstrual period. It is planned to start with low-dose treatment to reduce the risk of overstimulation and multiple pregnancy.
In-vitro fertilisation ((IVF) In Vitro Fertilisation), is considered as the third-line treatment in PCOS-related infertility. It should be preferred in the absence of response to ovulation induction treatments or in the presence of additional infertility factors.