Polycystic Ovary Syndrome (PCOS) for USMLE

This video will cover Polycystic Ovary Syndrome (PCOS) for USMLE. We will be going over pathophysiology, clinical signs and symptoms and management.

Pathophysiology
Underlying cause is unkown but there is a much higher LH production than FSH production. LH activates theca cells to produce testosterone and the granulosa cells are usually secreted by FSH and there will be low estrogen. In obese patients there is a lot of aromatase which converts testosterone into estrogen. This can lead to endometrial hyperplasia. There is also insulin resistance due to post-receptor problem, not necessarily associated with weight. Also there is association with metabolic syndrome which is Diabetes Mellitus obesit CVS HTN dysplidemia. There is also a decrease in SHBG so there is increase free testosterone.

Signs and symptoms are anvoluation, hyperadrogenism, polycystic ovaries on Transvaginal ultrasound greater than 12 cysts. Patients also have irregular menses, due to high estrogen and lack of progesterone. Leads to high levels of endometrial hyperplasia and the shear weight causes the bleeding. Acanthosis nigricans which is hyperpigmentation in fold of neck and fingers. Infertility or subfertility due to decrease amount of ovulation. Metabolic syndrome is Hypertension, CVS, Dyslipidemia, Obesity, and Diabetes Mellitus type 2. There will also be hirsutism, acne and alopecia.

Still this is a diagnosis of exclusion so must test the thyroid, prolactin levels, primary ovarian failure (high FSH, LH), Late onset CAH so look for 17OH progesterone, Adrogen tumors by looking at androgen index, DHEAS, Cortisol. Then TVUS if greater than 12 cyst in both ovaries. 2hr GTT, GMI, Lipid Profile and BP.

Treatment depends on outcome. Diet and exercise and metformin to address the effects of metabolic syndrome can help regain fertility. First step in management is give Oral Contraceptive to prevent endometrial hyperplasia and prevent cancer, regulates menses. Also estrogen blocks LH and diminishes the androgen to diminish hirsutism and acne. Antiandrogen helps hirsutism acne alopecia. If fertility is the issue than clomiphene and ovarian drilling.