Description
Heterogeneous androgen excess syndrome characterized by some or all of the following:
- Hirsutism
- Secondary amenorrhea (due to anovulation)
- Obesity
- Hyperinsulinemia
- Infertility
- Bilaterally enlarged polycystic ovaries
ICD-9 codes
- 256.4 polycystic ovaries
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Epidemiology
- 6%-7% prevalence among reproductive-aged women
- Higher prevalence in overweight or obese women
- Polycystic ovaries are common on ultrasound, but most are asymptomatic.
Causes
- May be insulin resistance with resultant hyperinsulinemia stimulating excess ovarian androgen production
Complications
- Chronic anovulation may lead to increased risk for:
– Endometrial hyperplasia
– Endometrial cancer
– Infertility
- Increased risk for ovarian hyperstimulation syndrome during ovulatory induction, resulting in multifetal pregnancy
- Increased risk for complications of pregnancy including gestational diabetes and hypertensive disorders
- Insulin resistance including type 2 diabetes mellitus
- Cardiovascular disease
- Metabolic syndrome
History
- Presenting symptoms in polycystic ovary syndrome (PCOS):
– 74% infertility
– 70% menstrual dysfunction (amenorrhea or dysfunctional uterine bleeding)
– 69% hyperandrogenism (hirsutism and/or acne)
– 41% obesity
– 20% no symptoms
- Also ask about
– Current medication use
– Hair loss
– Lipid disorders
– Hypertension
– Mood disturbance
– Sleep apnea
– Exogenous androgen use
Physical exam
- Measure
– BP
– Height and weight to calculate BMI
– Waist circumference (waist-hip ratio >0.85)
- Obesity may occur in 70% of patients.
- Perform pelvic examination to assess ovarian size
- Clitoromegaly rarely associated with PCOS; if present, look for other causes
- Look for stigmata of hyperandrogenism and insulin resistance such as:
– Deep voice
– Temporal balding and acne
– Hirsutism (70% of women with PCOS)
– Androgen alopecia (infrequent)
– Acanthosis nigricans; features include: velvety, mossy, verrucous, hyperpigmented skin located on neck,
axillae, under breasts, or on vulva
Making the diagnosis
- Diagnostic criteria may include
– Hyperandrogenism (presence of hirsutism or biochemical hyperandrogenemia)
– Oligomenorrhea or amenorrhea
– Polycystic ovaries on ultrasound
- Rotterdam Consensus Criteria 2003 guidelines require at least two of these three criteria.
- National Institutes of Health Criteria 1990 require hyperandrogenism and oligomenorrhea or amenorrhea.
- Updated Androgen Excess Polycystic Ovary Syndrome Society 2009 guidelines require hyperandrogenism plus at least one of oligomenorrhea/amenorrhea or polycystic ovaries.
- All criteria recommend excluding other possible causes.
