Paediatrics: Polycystic ovarian syndrome
Polycystic ovarian syndrome (PCOS) is a common (5 to 10%) heterogeneous condition, affecting females of reproductive age that is increasingly identified in the adolescent population.
Polycystic ovarian syndrome
Polycystic ovarian syndrome (PCOS) is a common (5 to 10%) heterogeneous condition, affecting females of reproductive age that is increasingly identified in the adolescent population. It is a life-long condition characterised by chronic anovulation, disordered gonadotrophin release, ovarian and adrenal hyperandrogenism, and insulin resistance.
The pathogenesis of PCOS is uncertain, however, both genetic and environmental factors are thought to play a role. Risk factors include a low birth weight for gestational age, premature adrenarche, atypical early pubertal development and obesity. A family history of PCOS is often observed.
The current diagnostic criteria for PCOS are defined as the presence of any two of the following three features:
- Oligo-and/or anovulation.
- Clinical or biochemical evidence of hyperandrogenism, provided other aetiologies of androgen excess (e.g. congenital adrenal hyperplasia, androgen-secreting tumours, Cushing’s syndrome) have been excluded.
- Polycystic ovaries on US scan (i.e. the presence of 12 or more follicles in each ovary, measuring 2–9mm in diameter, and/or increased ovarian volume (>10mL)).
The clinical and biochemical features of the syndrome are variable and the combination and degree of expression of these features vary between individuals.
Typical signs and symptoms develop during or after puberty and may include any of the following:
- acanthosis nigricans.
Laboratory finding includes:
- Elevated androgen concentrations (e.g. testosterone; dehydroepiandrosterone sulphate (DHEAS)).
- Elevated plasma LH: FSH ratio.
- Decreased sex hormone-binding globulin (SHBG) concentrations.
- Hyperinsulinaemia (fasting, oral glucose tolerance test (OGTT), IVGT samples).
- Decreased IGFBP-1 concentrations.
PCOS is recognized to have important long-term health implications and is particularly associated with a range of abnormalities that are characteristic of the metabolic syndrome. These include hyperinsulinaemia, impaired pancreatic β-cell function, the development of obesity, hyperlipidaemia, and an increased risk of T2DM and cardiovascular disease in later life. In addition, chronic anovulation is thought to carry an increased risk of endometrial cancer.
Treatment of PCOS is symptomatic and is directed at the presenting clinical problems. Lifestyle modifications are an important first-line intervention particularly when obesity is evident. Other treatment approaches include the use of the following drugs:
- Metformin (insulin sensitizer).
- Combined oral contraceptive pill (suppress ovarian hyperandrogenism).
- Spironolactone (anti-androgen).
- Cyproterone acetate (synthetic progesterone—anti-androgen).
- Flutamide (anti-androgen).
Cosmetic treatments such as electrolysis, laser hair removal, waxing, and bleaching, and use of topical depilatory creams may be used when hirsutism is a predominant clinical feature