hey everybody welcome back to another
lesson this lesson is on polycystic
ovary syndrome or PCOS so we're going to
talk about what this condition is some
of the risk factors for getting this
condition we're also gonna talk about
some of the other medical conditions
that are associated with PCOS and we're
going to talk about a method to diagnose
this condition in ways to treat it so
what is polycystic ovary syndrome if we
actually break down the word polycystic
the prefix poly means many are multiple
cysts refers to cysts and the suffix ik
means pertaining to so what this
condition is is a syndrome of many or
multiple ovary cysts or cysts in the
ovary so it is actually the most common
endocrinology Col disorder in a
reproductive age women worldwide it's
actually estimated to have a prevalence
between anywhere from five to fifteen
percent you can see in these images here
oftentimes women are affected with acne
and hirsutism or excessive hair growth
in this condition it is actually a
multifactorial disease which means that
there are many moving parts but if we
were to boil it down into one statement
this condition involves excess
production of androgens or male sex
hormones so what that means is that
oftentimes majority of the cases have
what we call a functional ovarian
hyperandrogenism which means that their
ovaries produce excess of male sex
hormones or excessive amounts of
androgens so we have high levels of
androgens these androgens lead to
altered and added troponin levels and
this leads to issues with ovulation
oftentimes it can inhibit or prohibit
ovulation from occurring what are some
of the risk or associated factors of
PCOS
one of the main risk factors for getting
PCOS is genetics when we look at twin
studies especially with monozygous twins
so identical twins if one twin has PCOS
the other twin is highly likely to also
have PCOS as well so that's indicating
there's a genetic component and we also
see that when we look at first-degree
relatives with PCOS first-degree
relatives to the individual PCOS are
also at a high risk of having PCOS
themselves so there's
in genetic components in PCOS the second
risk factor is environmental influences
this is tied in with the third risk
factor being obesity especially with
pre-pubertal obesity so obesity before
onset of puberty another risk factor is
early onset menurkey this is more to be
an Associated factor so individuals with
earlier onset of menarche are more
likely to have PCOS the fifth risk
factor is being large or small for
gestational age so if you were born
larger than average or smaller than
average the extremes of weight or size
you're more likely to have PCOS the
sixth is actually valproic acid use so
using valproic acid which is a
anti-seizure medication you are at a
higher risk for having PCOS as well and
the seventh is a question mark as there
is a hypothesis that having PCOS could
be related to fetal androgen exposure so
having exposure to androgens during
pregnancy so if your mom was exposed to
higher than average levels of androgens
you could be at a higher risk for having
PCOS yourself so what are some of the
clinical features of PCOS we break down
the clinical features of PCOS into three
to four categories the first category is
menstrual irregularity or chronic and
ovulation so as we mentioned before
because of those high androgen levels
there's altered and added troponin
levels or disrupted in a drop and
release leading to alterations or a
disruption of menstrual cycles so your
menstrual cycle timing can be off or
delayed or irregular so with menstrual
irregularity we may see a legal memoria
which is less than nine cycles per year
or you could have complete ayman area
which means that you're not having any
periods at all the second category of
clinical features in PCOS relates to
that high level of androgens or the high
level of male sex hormone so that high
level of androgens we call hyper and
drogyn ism so hyper just means high or
above so hyperandrogenism leads to
characteristic findings that we see
patients with PCOS one of them is acne
vulgaris oh mention this before women
with PCOS because of this
hyperandrogenism component of PCOS they
have issues with acne they can also have
issues with hirsutism or excessive hair
growth so you can see it on the face and
other parts of the body another one that
is not often talked about is alopecia or
hair loss so they can actually have some
components of male pattern baldness due
to this increased hyperandrogenism so we
can see some alopecia as well with
regards to the hyperandrogenism in PCOS
the third component is the polycystic
ovaries this is PCOS after all
polycystic ovary syndrome so there are
multiple cysts within the ovary
oftentimes in the fourth category of
clinical features in PCOS is a risk
factor that we actually talked about and
that is being overweight or obese
so in fact oftentimes the majority of
patients of PCOS are overweight or obese
so this is actually a significant
finding in these patients what are some
of the associated comorbidities or
conditions that we find are more likely
to occur in patients with PCOS one of
those associated comorbidities is being
obese but also having what we call
metabolic syndrome so metabolic syndrome
is a syndrome that involves elevated
blood pressure so they often have
hypertension they have high levels of
lipids in their blood so hyperlipidemia
or disc lipedema
and they also have central obesity so
it's connected with obesity but has a
couple of other components as well so
obesity and metabolic syndrome are
oftentimes associated comorbidities with
PCOS another one is impaired glucose
tolerance in type 2 diabetes because of
the obesity and metabolic syndrome this
makes sense we're gonna have issues with
impaired glucose tolerance and impaired
insulin sensitivity that can ultimately
lead to type 2 diabetes
another one is endometrial cancer
because a patient with PCOS is
oftentimes in ovulatory they don't have
regular menstrual cycles or they are
completely amenorrhea which means that
they have no menstrual cycles they have
unopposed as
unopposed estrogen means that their
endometrial lining continues to grow and
it can lead to endometrial hyperplasia
so large or thickened and demetria which
can ultimately lead to endometrial
cancer if there is longstanding or
chronic unopposed estrogen so it's
important to have opposed estrogen which
means that we want to get these patients
on progestin containing oral
contraceptives which we'll talk about
later on in this lesson
another associated comorbidity is
infertility infertility is due to the
fact that they are not ovulating so
they're not actually releasing an egg
which means that they're not able to get
pregnant another associate comorbidity
is obstructive sleep apnea oftentimes
obstructive sleep apnea can be related
to the obesity component so if they have
a lot of weight around their neck this
can actually lead to obstruction so it
can obstruct the airway leading to
obstructive sleep apnea these patients
can also have issues with depression and
anxiety cardiovascular disease so
obesity and metabolic syndrome are
associated with this cardiovascular
disease impaired glucose tolerance and
type 2 diabetes but also this
obstructive sleep apnea can all lead to
an increase your risk for having
cardiovascular disease and they can also
have issues with non-alcoholic fatty
liver disease and this is ultimately
related to impaired glucose tolerance
insulin resistance and the type 2
diabetes component of their associate
comorbidity so they can get a lot of fat
production and accumulation around the
liver leading to liver inflammation and
ultimately liver disease if not dealt
with appropriately so how do we diagnose
PCOS it's important to recognize that
PCOS is a diagnosis of exclusion which
means that we have to rule out or
exclude many other conditions that could
be causing some of the signs and
symptoms we see in PCOS like the
menstrual irregularities or Aemon areia
or the signs and symptoms of hyper
androgen ism so one of the first things
you want to do is you want to do a urine
pregnancy test or you PT or a beta HCG
so if either of these are positive that
means that they are pregnant so you want
to rule out pregnancy because pregnancy
can cause amenorrhea as well you then
want to move on to looking thurman
occassions so some medications could be
explaining some of these signs and
symptoms like androgenic steroids or
dopamine antagonists you then want to
look at a TSH or a thyroid stimulating
hormone to see do these patients have
thyroid disease you want to rule out
thyroid disease because hypo or
hyperthyroidism can lead to similar
issues with oligo or amenorrhea as well
you then move on to looking at prolactin
to see do these patients have
hyperprolactinemia there's many
different causes of hyperprolactinemia
some medications can do this so dopamine
antagonists can lead to
hyperprolactinemia they may have a micro
or macro adenoma there's many different
causes that could be leading to a
hyperprolactinemia state but you still
want to check their prolactin levels to
see do they have hyperprolactinemia
because hyperprolactinemia can cause
issues with their menstrual cycle and
the timing of the menstrual cycle as
well you then can move on to looking at
their FSH or follicle stimulating
hormone their luteinizing hormone or LH
and estrogen levels this can help us
rule out do these patients have hypo and
added tropic hypogonadism and then you
can look at 17 hydroxy progesterone to
see if these patients have what we call
non classical congenital adrenal
hyperplasia this condition ncc a h can
actually mimic PCOS quite a bit and it's
important to rule this condition out we
can then look at androgen levels see
do they have hyperandrogenism so
hyperandrogenism could be due to many
things it could be due to PCOS or it
could be caused by an androgen secreting
tumor so it's important to rule those
things out as well and in some cases you
may want to do a progestin challenge
this can see if this patient has an
outflow obstruction so it's important to
exclude disorders that mimic PCOS some
of these include pregnancy some of the
medications we talked about before
steroid diseases hyperprolactinemia non
classic congenital adrenal hyperplasia
or is there an androgen secreting tumor
that
the explaining the high levels of
androgens as opposed to it being caused
by PCOS this is a possible guideline
that you can use to exclude certain
conditions that mimic PCOS not every
clinician is going to use this guideline
but this is a possible guideline that
could be used so this can often be used
for evaluating
amenorrhea particularly so any issues
with menstrual cycles you could use this
algorithm here to see are any of these
causing that problem with their
menstrual cycle so again it's important
to rule out PCOS mimics this is a
diagnosis of exclusion so we have to
exclude all those other possible causes
once we have done that once we have
excluded those other causes we then use
what we call the Rotterdam criteria to
make a diagnosis of PCOS so there's
actually three components of the
Rotterdam criteria
the first one is menstrual irregularity
so that could be a legal menorah or a
manner so if they have either of those
if they have at least one of those
that's one point on the Rotterdam
criteria the second is having signs and
symptoms or clinical evidence or
laboratory evidence of hyperandrogenism
or high levels of androgens
so again signs and symptoms and/or
laboratory findings and the third part
of the Rotterdam criteria is polycystic
ovaries the best test to assess whether
a patient does have polycystic ovaries
is to do a transvaginal ultrasound or T
V us there could be a pelvic ultrasound
to look to see if they do have
polycystic ovaries but the best one is
actually this transvaginal ultrasound
you have to have two or more of these
criteria in order to meet the Rotterdam
criteria for a diagnosis of PCOS that
makes the diagnosis official there's
also this other diagnostic criteria from
the androgen excess Society or AES
this criteria there's three of them you
need all of these criteria
they're very similar to the Rotterdam
criteria except basically the menstrual
irregularity and the polycystic ovaries
are combined into one so those are you
have to have signs of symptoms and/or
laboratory findings of hyperandrogenism
you need menstrual irregularity or
polycystic ovaries and you need to have
excluded all the other disorders that
might be explaining hyperandrogenism
menstrual irregularity or polycystic
ovaries so very similar to the Rotterdam
criteria so again
PCOS is a diagnosis of exclusion
oftentimes we use the Rotterdam criteria
and the three criteria are menstrual
irregularity hyperandrogenism and
polycystic ovaries and you need two or
more for the diagnosis according to the
Rotterdam criteria once we have made the
diagnosis how do we treat PCOS the first
part of the treatment of PCOS is a
lifestyle modification it's very
important to have a very good diet so a
calorie restrictive diets a low
carbohydrate diet and exercise so those
two are very critical in treating PCOS
so first and foremost is lifestyle
modification smoking cessation as always
is always good but I'm gonna talk about
why I say that here in a moment and in
fact if you have extremely good
lifestyle modification a very good
healthy diet that is calorie restrictive
low carbohydrate and have good exercise
this can actually lead to improvement in
menstrual cycles and improvement in
those signs and symptoms of hirsutism or
the excessive hair growth so can
actually improve those symptoms
especially if at least five to ten
percent of your weight has been lost
after the lifestyle modification we
break down the treatment methods into
subcategories
the first couple of categories I want to
talk about are in women who don't want
to get pregnant so that's very critical
here we use these treatment methods in
women who don't want to get pregnant so
the first one is contraception the first
one we use is combined oral
contraceptive COCs this is first-line
treatment it helps treat many parts of
PCOS in fact one of those is menstrual
irregularities
it helps treat acne and hirsutism so the
excess of hair growth again it reduces
the risk of endometrial hyperplasia and
endometrial cancer because it prevents
that unopposed estrogen it allows
menstrual periods to occur so you don't
get that hyperplasia of the endometrium
the second category that we talk about
to treat is hyperandrogenism so as I
mentioned here these combined oral
contraceptives can be used to treat
signs the symptoms of hyper androgen ism
like the acne hirsutism but after a
while oftentimes it's months and months
if you don't see improvement in these
symptoms we move on to these other
treatments for the hyperandrogenism
specifically one of those is finasteride
a 5 alpha reductase inhibitor another
one is spironolactone so spironolactone
can be used as it is anti androgenic and
you could use a topical eflornithine
cream as well so these could be used to
help treat some of those symptoms like
the acting hirsutism the eflornithine
cream is only used for the hirsutism so
it helps with the hair growth so again
don't use these when you are trying to
get pregnant because these can actually
effect go nate'll development if you're
having a baby boy so don't use these
treatments during pregnancy and the last
treatment in the hyperandrogenism
category is the in a de trop and
releasing hormone agonists so you only
use these if these other treatments that
you've tried before really haven't
helped you with your signs and symptoms
again don't use these two categories if
you're trying to get pregnant so they're
only used for women who don't want to
get pregnant the next category is
related to associated conditions of PCOS
we talked about how associated
conditions like obesity and metabolic
syndrome and impaired glucose tolerance
are all associated with PCOS so
metformin is actually a very important
treatment in PCOS patients especially
with PCOS patients who have type 2
diabetes oftentimes metformin is
first-line for type 2 diabetic patients
anyways so we use metformin here as well
to help
their insulin sensitivity and glucose
tolerance and it can also help regulate
menstrual cycles as well and it can help
with their weight loss too again these
three categories are in women who don't
want to get pregnant but what about
women who do want to get pregnant so the
last category we're going to talk about
here for treatment is infertility and
the first-line treatment for infertility
is known as clomiphene so we use koma
féin to help ovulate to help increase
ovulation you can also use Electra's all
that's another newer treatment for
ovulation purposes as well and there's
also an adjunct treatment that we can
use in addition to clomiphene or
letrozole and that is actually metformin
again so metformin can actually help
prevent ovarian hyperstimulation
syndrome
so using metformin with clomiphene or
letrozole can actually help with
infertility and help prevent something
we call ovarian hyperstimulation
syndrome what's important here is that
you want to stop metformin once you are
pregnant I hope you found this lesson
helpful and informative
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thank you so much for watching and I
hope to see you next time