Diagnosis and Treatment of Polycystic Ovary Syndrome
Background: Polycystic ovary syndrome (PCOS) is found in 7 percent of women. It is thought to be caused by a disordered feedback loop between the ovary and the hypotha-lamic-pituitary axis, which leads to derange-ments in the release of luteinizing hormone in the presence of normal follicle-stimulating hormone. There also appears to be concomi-tant insulin resistance with compensatory hyperinsulinemia. Obesity probably increases glucose intolerance. Women with PCOS have higher rates of infertility and are at increased risk of pregnancy loss and complications, including gestational diabetes.
Diagnostic criteria for PCOS include oligo-ovulation or anovulation (generally defined as fewer than six to nine menstrual cycles per year) and clinical or biochemical signs of hyperandrogenism in the absence of other etiologies. Clinically, hyperandrogenism manifests as acne and hirsutism, although these findings may be absent. Testosterone levels are not reliable and can be affected by a number of factors.
Polycystic ovaries are detected by ultra-sonography and typically involve 10 to 12 small follicles closely spaced bilaterally on the peripheral edge of the ovaries. The differential diagnosis includes congenital adrenal hyperplasia, Cushing’s syndrome, hyperpro-lactinemia, thyroid disease, and tumor.
Recommendations: Treatment should be individualized. Weight loss is recommended when indicated to reduce cardiovascular risks and risks associated with diabetes. Women with PCOS have been shown to be success-ful in losing modest amounts of weight.
Metformin (Glucophage) in combination with lifestyle changes may be helpful in promoting weight loss in obese patients with PCOS. A glucose tolerance test should be performed regardless of weight. Clomiphene (Clomid) and metformin are useful in inducing ovula-tion in patients seeking fertility, but evidence does not support their use in combination. Metformin may be continued into pregnancy and may decrease miscarriage rates. Oral con-traceptives can be used to regulate periods and to decrease the risk of endometrial cancer, which is associated with obesity and chronic anovulation (but not necessarily PCOS). Pro-gestin-only pills can be used in patients with a strong history of thrombophilia.
Source: Legro RS. Clinical crossroads. A 27-year-old woman with a diagnosis of polycystic ovary syndrome. JAMA February 7, 2007;297:509-19.
| Copyright © 2007 by the American
Academy of Family Physicians. |
