in polycystic ovary disease, enlarged ovaries with thickened sclerotic capsules and an abnormally high number of follicles are present. the follicles may concurrently exist in varying states of growth, maturation, or atresia.
The prevalence of polycystic ovaries is difficult to accurately quantify. the inclusion criteria of most studies limit participants to those with specific clinical symptoms or syndromes and thus preclude a full accounting. in other studies, control subjects without polycystic ovaries often have symptoms that are associated with polycystic ovarian syndrome. Thus, a dilemma of nomenclature surrounds this clinical entity.
Most authors agree that polycystic ovaries are present in 3-7% of women worldwide. almost 75% of women with irregular menses and/or infertility may have polycystic ovaries, as determined with both radiologic and biochemical criteria. Polycystic ovaries have been found with ultrasonography in more than 50% of women with regular menstrual cycles as well; however, most of these women had some degree of hirsutism, acne, or male-pattern baldness
* Infertility is the most common clinical finding in patients with polycystic ovarian syndrome. low levels of circulating FSH and increased androgen production in the ovary prevent follicular maturation and ovulation. * Endometrial adenocarcinoma has been associated with polycystic ovarian syndrome. Unopposed estrogenic stimulation of the endometrium is known to increase the risk of endometrial hyperplasia and its subsequent transformation into endometrial carcinoma. in addition, the risk of breast cancer may be increased. * Secondary effects of the elevated levels of circulating androgens include, but are not limited to, hirsutism, abnormal or absent menstrual cycles, virilization, and dysmenorrhea.Sex
Polycystic ovarian disease occurs only in females.Age
* Polycystic ovaries can be diagnosed in patients of any age, from menarche through menopause. * Typically, women in their 20s present with difficulty conceiving. * although uncommon, some patients between ages 10 and 20 years present with primary amenorrhea.Clinical Details
Most patients in whom polycystic ovarian syndrome is ultimately diagnosed initially present with infertility, amenorrhea, or irregular menses. although most woman present in their 20s or 30s, polycystic ovarian disease can affect females of any age, from menarche to menopause. Findings in almost 75% of patients meet the radiologic criteria for polycystic ovarian syndrome. Primary amenorrhea is a well-known but uncommon presentation.
Although infertility is the most common presentation in affected patients, polycystic ovarian syndrome may be associated with obesity and insulin resistance, among other symptoms. A number of patients are identified only when they present with unrelated complaints; these patients may believe the symptoms that are associated with the syndrome are not of sufficient clinical significance to warrant medical attention.
A second population of patients presents with systemic signs of androgen excess—namely, hirsutism, acne, or male-pattern baldness. in approximately one half of the patients, sonograms show polycystic ovaries.
Additionally, a significant number of patients with unrelated complaints are incidentally found to have polycystic ovaries. further detailed clinical evaluation reveals that approximately one half of the patients in this group have typical signs and symptoms of the syndrome (ie, hirsutism, acne, infertility) and that one quarter have related symptoms such as obesity, irregular menses, or insulin resistance. the remaining one quarter of the patients may not have any clinically evident abnormality.Preferred Examination
Polycystic ovaries are most often diagnosed by means of laboratory studies. the initial screening tests may include determinations of the blood serum levels of thyroid-stimulating hormone (TSH), FSH, LH, and prolactin (PL). the ratio of the FSH level to the LH level is useful in the diagnosis. TSH or PL levels may be useful in identifying an etiology, such as hyperthyroidism or a prolactinoma. in some patients, testosterone and dihydroepiandrosterone sulfate (DHEAS) levels or a progesterone challenge are useful.
Typically, a radiologic evaluation for polycystic ovaries is reserved for patients who have equivocal laboratory findings. However, radiologists make a significant number of incidental diagnoses. Should the radiologist’s assistance be requested in the diagnosis of polycystic ovarian syndrome, the imaging method of choice is transabdominal and/or transvaginal ultrasonography. Magnetic resonance imaging (MRI) is useful as an adjunct; however, although MRI is more sensitive than ultrasonography, its findings are less specific.
Polycystic ovarian syndrome is not a primary disease process. When polycystic ovaries are discovered at radiologic examination, further diagnostic tests are needed to determine the etiology.Polycystic ovaries typically exhibit 3 characteristics on ultrasonographic examination: bilateral enlarged ovaries, multiple small follicles, and increased stromal echogenicity.
Usually, the ovaries are enlarged symmetrically, and the shapes change from ovoid to spherical. Ovarian volume can increase by as much as 6 mL; however, almost 30% of patients with a biochemical and pathologic diagnosis of polycystic ovaries have no increase in ovarian volume.
The typical polycystic ovary contains numerous follicles at any given time. the follicles are small (0. 5-0. 8 cm), and no dominant follicle is present. Characteristically, the follicles are peripherally located in the cortex; however, they can occur anywhere in the ovarian parenchyma. the diagnosis of polycystic ovaries should be reserved for patients with at least 5 of these follicles in each ovary.
Typically, the ovaries are hypoechoic in relation to the surrounding pelvic fat and myometrium. Polycystic ovaries often display increased echogenicity; however, as many as one third may remain isoechoic or hypoechoic relative to the myometrium.
Degree of Confidence
Ultrasonography has a largely corroborative role in the diagnosis of polycystic ovarian syndrome. in a patient with a biochemical diagnosis of polycystic ovaries, ultrasonographic findings may confirm the clinical diagnosis, but they cannot exclude it. Alternatively, the incidental discovery of polycystic ovaries during ultrasonography is not a reliable indicator of polycystic ovarian syndrome.What treatments are available for polycystic ovarian syndrome?
Treatment of PCOS depends partially on the woman’s stage of life. for younger women who desire birth control, the birth control pill, especially those with low “androgenic” (male hormone–like) side effects can cause regular periods and prevent the risk of uterine cancer. for women who do not require birth control, treatments that cause a woman to have a period four times a year is all that is required.
For acne or excess hair growth, a water pill (diuretic) called spironolactone may be prescribed to help reverse these problems. the use of spironolactone requires occasional monitoring of blood tests because of its potential effect on the blood potassium levels and kidney function. Propecia, a medicine taken by men for hair loss, is another medication that blocks the effect of male hormones on hair growth. Both of these medications can affect the development of a male fetus and should not be used if the woman desires to become pregnant.
For women who desire pregnancy, a medication called clomiphene (Clomid) can be used to induce ovulation (cause egg production). in addition, weight loss can normalize menstrual cycles and often increases the possibility of pregnancy in women with PCOS. other, more aggressive, treatments for infertility (including injection of gonadotropin hormones and assisted reproductive technologies) may also be required in women who desire pregnancy and do not become pregnant on Clomid therapy. Obesity that occurs with PCOS needs to be treated because it can cause numerous additional medical problems. Consultation with a dietician on a frequent basis is helpful until just the right individualized program is established for each woman.
Metformin (Glucophage) is a medication used to treat type 2 diabetes. this drug affects the action of insulin and is useful in reducing the symptoms of PCOS.
Finally, a surgical procedure known as ovarian drilling can help induce ovulation in some women who have not responded to other treatments for PCOS. in this procedure a small portion of ovarian tissue is destroyed by an electric current delivered through a needle inserted into the ovary.