• Credits
  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

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• Q. When does the menstrual irregularity of PCOS begin?

  • At the time of menarche!

• Q. What is the characteristic gonadotropin dynamics in PCOS?

  • GnRH pulse amplitude is altered, leading to the preferential release of LH in preference to FSH
  • Thus, LH is high, and FSH is relatively lower with a high LH/FSH ratio
  • This is not seen in all cases though
  • Prenatal androgen exposure may produce this risk – it is proposed

• Q. Apart from classical oligo/amenorrhea, which other menstrual abnormalities are seen with PCOS?

  • Dysfunctional uterine bleeding- heavy menstrual bleeds, frequent menstrual bleeds
  • Polymenorrhea
  • Menorrhagia
  • Intermittent breakthrough bleeding

• Q. Why are women with PCOS at increased risk of Endometrial carcinoma?

  • Anovulation unopposed estrogen action on endometrium → little or no progesterone / luteal phase
  • Hyperinsulinemia → increases IGF1 activation
  • Obesity itself is a risk factor
  • Hyperandrogenemia is a risk factor

• Q. How to monitor for Endometrial risk using TVS?

  • On TVS, endometrial thickness <7 mm – rules out endometrial hyperplasia /carcinoma

• Q. What are the typical ovarian histological changes in PCOS?

  • Increase the number of preantral and small antral follicles arranged in the periphery
  • Increase stroma
  • thick and sclerotic cortex

• Q. What is the USG appearance of PCOS?

  • Increase ovarian volume > 10 ml
  • Increase the number of small follicles of 2-9 mm (Rotterdam- 12 , AES- 25 using high-frequency probe)
  • Number of follicles and ovarian size reduce with age, and hence for women >40 - age-specific criteria must be used

• Q. What are changes in the follicular fluid?

  • Fluid has more androgen and less estrogen

• Q. What happens to follicular development in PCOS?

  • Initial development is fine- in fact exaggerated
  • Later development -follicular arrest
  • Development till secondary – early tertiary follicle is fine- further development is arrested
  • Typical grow till 5-8 mm in size

• Q. What is the problem in women with PCOS with regards to pregnancy?

  • Increase the risk of anovulatory infertility
  • Increase abortion risk in pregnancy
  • Increase the risk of GDM
  • Preeclampsia
  • Preterm delivery
  • Neonatal ICU admission

• Q. What are the reason for increase pregnancy-related complications?

  • Increase low-grade inflammation
  • Associated obesity

• Q. What happens to the menstrual cycle of PCOS women as they age?

  • Menstrual cycles tend to become more regular as they age!
  • The age of menopause, however is not changed
  • The hyperandrogenism may persist after menopause
  • Hyperandrogenism

• Q. What percentage of women with PCOS have increased androgen levels?

  • 50-90%

• Q. What percentage of PCOS women are obese?

  • 50%

• Q. How does hyperinsulinemia produce hyperandrogenism in PCOS?

  • Increase activation of ovarian theca cells to produce androgens
  • Reduces SHBG increase of free testosterone

• Q. Do women with PCOS have an increased risk of NASH?

  • Yes
  • 30% of women with PCOS have ALT elevation
  • This is even more than diabetes!

• Q. what percentage of women with PCOS fulfill Metabolic syndrome criteria?

  • 43%

• Q. Do women with PCOS have an increased risk of diabetes?

  • Yes, type 2 diabetes

• Q. Which molecular defect in PCOS links PCOS with diabetes?

  • There is a defect in serine phosphorylation
  • Abnormal serine phosphorylation in Insulin receptor increase hyperinsulinemia
  • Abnormal serine phosphorylation in 17 alpha-hydroxylase (CYP17)  increase ovarian androgen production

• Q. Do women with PCOS have increased OSA?

  • Yes
  • They should be questioned about OSA

• Q. What are the lipid abnormalities in PCOS?

  • Increase TG
  • Reduce HDL
  • Increase LDL
  • Typical of metabolic syndrome

• Q. Do they have to increase CV risk?

  • Increased CV risk has not been documented yet

• Q. We know OCP causes increased VTE risk. Is PCOS itself associated with an increased risk of VTE?

  • This is not proven

• Q. What are the psychosocial manifestations of PCOS ?

  • More associated with :
  • Mood disorders- depression and anxiety
  • Eating disorder- binge eating

• Q. Summarize the clinical manifestations of PCOS?

  • 1. Reproductive abnormalities
    • Oligo/amenorrhea
    • DUB
    • Intermittent Breakthrough bleeds
    • Increase the risk of endometrial carcinoma
    • Ovulatory infertility
    • Pregnancy complications
  • 2. Hyperandrogenism
    • Hirsutism
    • Female pattern hair loss
    • Acne
    • Virilization- rare
  • 3. Metabolic abnormalities
    • Hyperinsulinemia
    • OSA
    • NASH
    • Metabolic syndrome
    • Dyslipidemia
    • IGT/type 2 diabetes
  • 4. Other
    • Increase mood disorder