PCOS the origin & course of the disease

PCOS. Whets wrong with it ?? The etiology and center of treatment: Biochemical criteria have now become the mainstay of the lesion.

A)                      One courses of OCP to all women coming four subfertility Tr those who have menst disorders?? Yes or NO;-- Presume that she is a PCO as because she is having Menst disorders in addition to subfertility Tràthen ovulation induction. A clinical presentation vary considerably and fails to display any common symptoms even when histology confirms PCOS. Therefore it is prudent to prescribe one course of OCP prior to Ovulation induction whoever comes with mens disorders with the apprehension that such woman may have rise of LH as she is having mens aberrations. ? In lean women an elevated LH on the main cause to augment rate of production of ovarian androgen. An elevated LH level is related to subfertility & abortion. By contrast, in obese PCOs the main driving force for hyperandrogenism it is hyperinsulinaemia. An elevated LH level is related to subfertility & abortion.

1)                       Degree of clinical presentation of PCOS varies. Polygenic, mutifactorial, Key elements are cycle disturbances, hyperandrogenaemia & obesity. In SE Asia –metabolic features however predominates.

Ovarian dysfunction is central-though there are many extra-ovarian aspects of these diseases. There is considerable heterogeneity of symptoms and .There may not be any symptoms at all. Further, the symptoms may change with time. Or symptoms may be precipitates with some by various factors of which gain in weight is a major factor in expression of the syndrome.

The symptoms are differently inherited. There are several interlinking factors that affect expression of the disease. Disorders of insulin metabolism are an important factor.

But fundamentally, it is a disorder of ovarian steroidogenesis where there is more production of androgens.

2)                       Tests for Hyperandrogenaemia when and how?  It is recommended that all women with PCOS should have conventional tests of total testoerone by traditional RIA.

Only those women who are clinically suspected to be suffering from Classical PCOSàthey are asked for estimation of Total Testosterone:-If the total testosterone exceeds > 4.8 n.mol/Lit-& the hirsutism/ acne/ androgenic alopecia are of recent onset then onlyà one should ask for detailed evaluation as to the source of androgen from adrenal/Ovaries by CT, CAH (17-)H progesterone) or Cushing syndrome.

We Should perform following just to qualify for Classical PCOS, Therefore, to document that one has classical PCOS – treating physician has to test for adrenal diseases by estimating serum 1) cortisol, 2) DHEASO4 ,3)  17-OH Progesterone, & 4) tests for pituitary dysfunction in the form of PRL, 5) Growth hormone-Acromegaly, Androgen secreting tumors of ovaries/adrenals( 6. CT abdomen)-

Relevance of FAI/ free testoerone & SHBG?-Hyperinsulinaemiaàlow SHBGàclinical hyperandrogenism-àthere is normal total T but elevated free Testosterone. 

The availability of mass spectrometry can detect testosterone accurately and upper limit of FT is 1.8 nmol/Lit.

 Some measure SHBG as a surrogate for the degree of for the degree of IR..

In obese womenà insulin acts as a cogonadotropin .Insulin cause augmentation of the action of LH on ovaries leading to hyperandrogenism.

3)                       Asymptomatic PCOS).--PCOS may exist without any symptom (Asymptomatic PCOS).

Treat according to the individuals need and Symptoms. In the general population PCOS may be observed as many as 20-40% of women but many do not exhibit any biochemical /endocrinological evidence. The primary feature is cycle disturbances, hirsutism, acne and abnormal endocrine profile like elevated LH, testosterone-, androsostenedione,

The secondary features are obesity (in UK about 40-50% of PCOS are overweight) & Hyperinsulinaemia. Biochemical criteria have now become the mainstay of the lesion.

C/F varies considerably and fails to display any common symptoms even when histology confirms PCOS.

4)                       Clinical Features and its relation with lifetime risks:--Spectrum of Clinical manifestation  of PCOS:-

Primary symptoms	Endocrine abnormality detected	Possible late squeal.
Obesity	Rise of androgens	DM/  HTN
Mens. disorders	LH high	Dyslipidemia
Infertility	Rise of Fast insulin.	CVS.
Asymptomatic	Rise of oestradiol, oestrone	Breast cancer.

N .B. Therefore it is prudent to prescribe one course of OCP prior to Ovulation induction whoever comes with mens disorders with the apprehension that such woman may have rise of LH as she is having mens aberrations.

` Biochemical criteria is the mainstay of diagnosis of PCOS-Fast hyperinsulinaemia.

USG & PCOS:_The greatest sensitivity of PCOS is ratio of Ovarian stromal area  vs. to total ovarian volume .Threshold marker of PCOS in USG is AMH level of > 35 p mol/Lit` and or total no of follicles are >19.CD / Pulsed Doppler USG have been employed in diagnosis PCOS. Some have also used 3D/MRI for diagnosis of PCOS.

Is LH estimation essential in a clinical suspected PCOS?. - No. But in fair number of PCOS cases there is rise of LH pulse & amplitude. Body weight has some relation with LH level and LH is high in women who are lean. What are the causes of ovarian hyperandrogenism? In lean women an elevated LH on the main cause to augment rate of production of ovarian androgen .By contrast in obese PCOs the main driving force for hyperandrogenism it is hyperinsulinaemia.

An elevated LH level is related to subfertility & abortion. But those PCOs who are associated with mens disorders and/or subfertility -in those casesàLH changes are as follows. In about 40-60% of PCOS cases do have elevated LH level.

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Definition of PCOS:-  There was a joint consensus meeting at Rotterdam in 2003,  by ESHRE)European Society of Human Reproduction and Embryology) & ASRM )American society  for reproductive Medicine) .Two criteria was considered essential:- A(Oligo-ovulation or complete anovulation B)  Clinical/Biochemical Hyperandrogenism & C) Polycystic ovaries as in USG  with the exclusion of other causes of such diseases.(Anovulation/hyperandrogenism and PCOM).Each ovary should contain at least No of follicles 10-12; size are 2-9 mm ; Volume > 10 cm²