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Polycystic ovary syndrome is a clinical syndrome characterized by mild obesity, irregular menses or amenorrhea, and signs of androgen excess (eg, hirsutism, acne). In most patients, the ovaries contain multiple cysts. Diagnosis is by pregnancy testing, hormone measurement, and imaging to exclude a virilizing tumor. Treatment is symptomatic.
Polycystic ovary syndrome occurs in 5 to 10% of women and involves anovulation or ovulatory dysfunction and androgen excess of unclear etiology. It is usually defined as a clinical syndrome, not by the presence of ovarian cysts. Ovaries may be enlarged with smooth, thickened capsules or may be normal in size. Typically, ovaries contain many 2- to 6-mm follicular cysts and sometimes larger cysts containing atretic cells. Estrogen levels are elevated, increasing risk of endometrial hyperplasia and, eventually, endometrial cancer. Androgen levels are often elevated, increasing risk of metabolic syndrome (see Obesity and the Metabolic Syndrome: Metabolic Syndrome) and causing hirsutism. Over the long term, androgen excess increases risk of cardiovascular disorders, including hypertension.
Symptoms and Signs
Symptoms typically begin during puberty and worsen with time. The typical symptoms are mild obesity, hirsutism, and irregular menses or amenorrhea. Some women have other signs of virilization, such as acne and temporal balding. Areas of thickened, darkened skin (acanthosis nigricans) may appear in the axillae, on the nape of the neck, and in skinfolds; the cause is high insulin levels due to insulin resistance.
Diagnosis
Ovulatory dysfunction is usually present at puberty, resulting in primary amenorrhea; thus, this syndrome is unlikely if regular menses occurred for a time after menarche. Examination usually detects abundant cervical mucus, reflecting high estrogen levels. The diagnosis is suspected if women have at least 2 typical symptoms.
Testing includes pregnancy testing, pelvic ultrasonography, and measurement of serum total testosterone, follicle-stimulating hormone (FSH), prolactin, and thyroid-stimulating hormone (TSH). Serum free testosterone level is more sensitive than total testosterone but is technically more difficult to measure (see Male Reproductive Endocrinology and Related Disorders: Diagnosis of primary and secondary hypogonadism).
The diagnosis requires at least 2 of the following 3 criteria:
In women meeting criteria, serum cortisol is measured to exclude Cushing's syndrome, and early-morning serum 17-hydroxyprogesterone is measured to exclude adrenal virilism. Serum dehydroepiandrosterone sulfate (DHEAS) is measured. If DHEAS is abnormal, women are evaluated as for amenorrhea (see Menstrual Abnormalities: Evaluation). Adult women with polycystic ovary syndrome are evaluated for metabolic syndrome by measuring BP and usually serum glucose.
Treatment
To reduce the risk of endometrial hyperplasia and cancer in women who do not desire pregnancy, clinicians can use an intermittent progestin (eg, medroxyprogesterone 5 to 10 mg po once/day for 10 to 14 days q 1 to 2 mo) or oral contraceptives. These treatments also reduce circulating androgens.
For hirsutism (see Hair Disorders: Hirsutism), physical measures (eg, bleaching, electrolysis, plucking, waxing, depilation) can be used. Eflornithine cream 13.9% bid may help remove unwanted facial hair. In adult women who do not desire pregnancy, hormonal therapy that decreases androgen levels or spironolactone can be tried.
Weight loss is encouraged. It may help induce ovulation, increase insulin sensitivity, and reduce acanthosis nigricans and hirsutism.
Metformin 500 to 1000 mg bid is used to help increase insulin sensitivity if weight loss is unsuccessful or menses do not resume. Metformin can also reduce free testosterone levels. When metformin is used, serum glucose should be measured, and kidney and liver function tests should be done periodically. Because metformin may induce ovulation, contraception is needed if pregnancy is not desired.
For women who desire pregnancy, infertility treatments (eg, clomiphene, metformin) are used (see Infertility: Treatment). Weight loss may also be helpful. Hormonal therapy that may have contraceptive effects is avoided.
Last full review/revision January 2010 by JoAnn V. Pinkerton, MD
Content last modified January 2010
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