Episode 139: What is PCOS - a podcast by Rio Bravo Family Medicine Residency Program

Episode 139: What is PCOS      

Future Dr. Salimi explains the pathophysiology, signs, and symptoms of PCOS. Diagnostic criteria and the basics of treatment are also discussed. Dr. Arreaza adds some comments about the treatment of obesity.  

Written by Elika Salimi, MS3, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.

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Hello there! My name is Elika and I am a third-year medical student at Western University of Health Sciences. Today I will be talking to you about polycystic ovary syndrome AKA PCOS.

• Do you have a female patient in her reproductive years with irregular menstrual cycles, or no menstrual cycles at all? 
• Is she unable to conceive a child? 
• Did she have an unexpected diagnosis of diabetes? 
• Does she have more acne than she would like, or has hair in unwanted or unexpected areas such as her chin?
• Does she have a hard time losing weight? 

If you answered YES to many of these questions, it is possible that your patient is suffering from polycystic ovary syndrome also known as PCOS, which is one of the most common endocrine disorders in women. 

Pathophysiology:

The exact pathophysiology behind this syndrome is unknown; however, per the American College of Obstetricians and Gynecologists committee, some studies have shown a strong association between PCOS and obesity. In a woman with obesity disorder, the excess adipose tissue ends up increasing peripheral estrogen synthesis and as a result, there is a decrease in peripheral sensitivity to insulin which means many of these women tend to have hyperinsulinemia. To be more detailed, it is important to mention that during these anovulatory cycles, the increase in estrogen, which is also unopposed estrogen with a lack of progesterone, can lead to endometrial hyperplasia and consequently increase the risk of endometrial carcinoma.

Clinical Features: 

Unless there is a clear history and physical or if perhaps there was an incidental ultrasound finding of polycystic ovaries, the diagnosis of PCOS is not exactly black-and-white. That is why it is important to increase awareness so that women can put the pieces of the puzzle together and come in to get evaluated. Multiple cysts in ovaries can present in patients without PCOS, and they are common in teenagers. To use the multiple cysts as part of the diagnosis, the patient has to be 2 years after menarche (AAFP). 

Some of these clinical symptoms typically start during adolescence displaying menstrual irregularities such as she could’ve had her period and then stopped getting it or she has a very delayed onset of her menstrual cycle. 

It is also possible to have spotty menstrual cycles also known as breakthrough bleeding or menorrhagia. And very important to many women, she could be infertile or have difficulties conceiving.

She could also have diabetes because of insulin resistance that comes with the metabolic syndrome that develops with PCOS, which is also increased if she has obesity. This obesity disorder going hand in hand with the metabolic syndrome, can also increase the risk of having sleep apnea, which could affect the quality of her sleep, finding herself more fatigued than she should be after adequate hours of rest. 

Other symptoms include skin conditions such as hirsutism which is basically male pattern hair growth in women in areas such as the upper lip, chin, around the umbilicus, back, or even buttocks. She could also have male pattern hair loss on the head or too much acne or oily skin or acanthosis nigricans which are these brown/velvety hyperpigmented streaks on the neck or axilla, or groin. She could also find herself more depressed or anxious.

Diagnosis:

The diagnostic criteria and treatments are mainly addressed in the Journal of Clinical Endocrinology & Metabolism, an evidence-based guideline for the assessment and management of polycystic ovary syndrome, and the American Family Physician Journal:

The diagnosis of PCOS requires the presence of at least two criteria that are not due to any other endocrine disorder such as thyroid disease or hyperprolactinemia, or other. 

1) Periods of oligo-ovulation and or anovulation which means she’s either having very low ovulatory cycles or she’s not ovulating at all. 

2) hyperandrogenism and this could be based on her clinical features or laboratory studies showing elevated testosterone levels or LH to FSH ratio and 

3) Seeing enlarged and/or polycystic ovaries on a pelvic ultrasound. This means that the pelvic ultrasound shows an ovarian volume of equal to or greater than 10 mL and/or there’s multiple cystic follicles that are about 2 to 9 mm in one or both of her ovaries which also usually tend to have a string of pearls appearance.

So, if you have 2 out of the 3, you have PCOS. 

There are ways to confirm that there is in fact hyperandrogenism by doing lab studies and this could mean that her testosterone levels are elevated, or her androstenedione is elevated as well as elevated dehydro-epi-androsterone sulfate (DHEAS) and of course we need to rule out pregnancy and other endocrine disorders as I mentioned earlier. However, if the clinical picture of hyperandrogenism is there then that fulfills the diagnostic criteria for PCOS even if the serum antigen levels are normal. 

This also applies to an elevated LH:FSH ratio of typically greater than 2 to 1 which is also a characteristic finding of most patients with PCOS but this is not exactly necessary for diagnosis. We also don’t need to find cystic follicles in order to diagnose PCOS. 

Treatment: 

In family medicine practices and even OB/GYN practice for PCOS the most common recommendation for all patients is to encourage them to increase their physical activity (exercise) and eat healthy and try to consider behavioral modifications to have a target BMI of ideally less than 25 kg/m² because this can reduce estrone production in adipose tissue.

Then we are thinking about ways to treat patients who are not planning to conceive versus those that are. 

• For those patients that are not planning to conceive the goal is to regulate their menstrual cycles and irregularities as well as their hyperandrogenism and to treat the comorbidities as well to overall improve their quality of life.

The first line treatment for hyperandrogenism to try to regulate menstrual cycle abnormalities is combined oral contraceptives also known as birth control pills. This also reduces endometrial hyperplasia which in turn can decrease the risk of endometrial carcinoma as mentioned earlier and it can reduce menstrual bleeding and you can reduce acne and try to assist with the hirsutism as well. As mentioned earlier, PCOS can also go hand-in-hand with insulin resistance or hyperinsulinemia and therefore we can also use metformin that can improve menstrual irregularities but also address the metabolic side of this as well. Summary: Diet, exercise, combined oral contraceptives, and metformin.

Some other more controversial medications to treat hyperandrogenism could be potassium-sparing diuretics such as spironolactone that also inhibits 17-a-hydroxylase or finasteride which is a 5-alpha-reductase inhibitor and flutamide which is an androgen receptor blocker. The mentioned examples are typically for those people that can’t really tolerate combined oral contraceptives. 

Other things to consider for those that are suffering from obesity syndrome are to possibly consider bariatric surgery if of course the criteria are met, and this is on a case-by-case basis. Bariatric surgery may be an answer to many of our metabolic problems that’s why it is now called metabolic surgery. 

• For patients who are planning to conceive the goal is to manage their comorbidities such as weight loss but also to try to induce ovulation.

Now the first-line therapy for inducing ovulation is a medication called letrozole which is an aromatase inhibitor that in turn reduces estrogen production stimulating FSH secretion and ultimately inducing ovulation, not to get too heavily into the weeds of how these medications work, but basically it improves pregnancy and live birth rate outcomes in patients who are infertile because of the fact that they have anovulatory cycles or a.k.a. they are not ovulating.

Then we also have clomiphene which is just an alternative to letrozole and has a different mechanism of action but it also stimulates ovulation by more particularly causing a pulsatile secretion of GnRH and in turn increasing FSH and LH as well, and this medication might be actually preferred over metformin monotherapy in women that are suffering from obesity syndrome who also have anovulatory infertility. However, apparently, clomiphene can cause more chance of multiple gestations versus letrozole.

Also, letrozole is preferred over clomiphene to induce ovulation because of a higher rate of live births, but we have the risk of multiple pregnancies with both these methods. Let’s talk about the second-line therapies.

As mentioned earlier we have this 2 to 1 ratio of FSH to LH in women with PCOS or at least a good amount of them. We said that that is not required to diagnose this disorder but we can also give women exogenous FSH plus human menopausal gonadotropin, but this is really a second-line treatment for ovulation induction and typically we go for second-line treatments if first-line therapies aren’t successful. But I will mention that using this exogenous gonadotropin is very expensive and it requires you to have access to specialized healthcare facilities and constant ultrasound monitoring so this may just not be feasible for many people but if you have the resources and it’s affordable for you then exogenous gonadotropins are actually preferred over clomiphene and metformin therapy.

Metformin can also use as a second-line monotherapy for fertility treatments and this in combination with clomiphene can increase pregnancy rates, especially in women who are suffering from obesity disorder, and of course, this is first-line therapy for insulin resistance.

Now if we’re talking about an invasive type of procedure for infertility it would be laparoscopic ovarian drilling which basically, we use a laser beam or surgical needle to reduce ovarian tissue to decrease its volume and try to reduce androgen production. Doing this can cause a hormone shift that can induce FSH secretion and ultimately improve ovarian function as well. This is also a second-line treatment for ovulation induction, but it can be performed as a first line if other indications for laparoscopy are present. 

Third-line therapy would be in vitro fertilization which means that basically we take mature eggs from ovaries and then we fertilize them with sperm in a lab and then the fertilized egg or the embryo is transferred to a uterus to be implanted.

For the management of hirsutism, the first-line therapy is usually non-pharmacological and that’s electrolysis or light-based hair removal with laser or photo-epilation. For acne, we can consider benzoyl peroxide or topical antibiotics if necessary.

Final thoughts: Now I know that was a ton of information but ultimately, we are trying to make women more aware of PCOS and let them know that they are not alone, also we are trying to reduce complications such as cardiovascular problems, diabetes, endometrial cancer, infertility or even pregnancy loss. The best we can do is try to educate more women because many are suffering from this condition and they have no idea. Again, my name is Elika Salimi, and I am a third-year medical student. If you have any questions, you can reach me at elika.salimi@westernu.edu.

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Conclusion: Now we conclude episode number 139, “What is PCOS.” Future Dr. Salimi explained that patients with Polycystic Ovary Syndrome present with: Hyperandrogenism, Oligo-ovulation or anovulation, and multiple cysts in ovaries. If your patient meets 2 out of the 3 criteria, then you can confidently give the diagnosis of PCOS. Dr. Arreaza reminded us that by treating obesity you are also treating PCOS. 

This week we thank Hector Arreaza and Elika Salimi. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

1. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology..ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome..Obstet Gynecol.2018; 131(6): p.e157-e171.doi:10.1097/AOG.0000000000002656
2. Hoeger KM, Dokras A, Piltonen T.Update on PCOS: Consequences, Challenges, and Guiding Treatment.The Journal of Clinical Endocrinology & Metabolism.2020; 106(3): p.e1071-e1083.doi:10.1210/clinem/dgaa839
3. Williams T, Mortada R, Porter S.Diagnosis and Treatment of Polycystic Ovary Syndrome..Am Fam Physician.2016; 94(2): p.106-13.pmid: 27419327.
4. Legro RS, Arslanian SA, Ehrmann DA, et al.Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab.2013; 98(12): p.4565-4592.doi:10.1210/jc.2013-2350.
5. International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018.https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf

 

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