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Polycystic Ovarian Syndrome By Katie Troyer
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Abstract:
Polycystic Ovarian Syndrome (PCOS) is a group of clinical findings and abnormalities which characterize this disorder. As the name implies, the ovaries present on ultrasound with multiple, small follicles (small fluid-filled sacs containing immature eggs) usually measuring less than five millimeters distributed around the periphery. The ultrasound appearance alone cannot diagnose PCOS. There are many clinical signs and symptoms which can include hyperandrogenism, hyperinsulinemia, hirsutism, AUB (Abnormal Uterine Bleeding), amenorrhea, oligo-ovulation, infertility, obesity, and several abnormal blood levels. As a sonographer it is important to recognize the ultrasound appearance of PCOS along with the many clinical findings that can effectively diagnose this disorder. The purpose of this discussion is to highlight key signs of the clinical and ultrasound findings that describe Polycystic Ovarian Syndrome.1
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Key Words:
Polycystic Ovarian Syndrome, PCOS, Abnormal Uterine Bleeding (AUB), Hyperandrogenism, Infertility, Amenorrhea
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Introduction:
Polycystic Ovarian Syndrome was first described by American gynecologists Irvin Stein and Michael Leventhal in 1935. PCOS is a common endocrine disorder. The prevalence of PCOS is estimated to occur in five to ten percent of women in their reproductive years. There are many similar clinical and laboratory findings that classify PCOS. Common features of Polycystic Ovarian Syndrome are hyperandrogenism, abnormal uterine bleeding, infertility, pregnancy loss, and obesity.
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Body:
A common feature of Polycystic Ovarian Syndrome is hyperandrogenism. This is an increase in production of male hormones such as DHEAS (Dehydroepiandrosterone Sulphate) and testosterone. Hyperandrogenism may result in oily skin, acne, and hirsutism. Hirsutism is excess growth of facial hair, hair between the breasts, or on the lower abdomen. In women suffering from hyperandrogenism, improvement can be obtained with a combination of medications. Oral contraceptive pills are very useful as well as drugs that reduce the secretion of androgen hormones or interfere with their reaction to the skin and hair cells. Hyperandrogenism is usually caused by insulin resistance or an increase in insulin secretion called hyperinsulinemia. This increase in insulin can stimulate the release of androgens. This in turn causes an increase in free estrogen which decreases the follicle stimulating hormone (FSH). The ovarian follicles are stimulated to grow but do not have enough FSH to continue their growth normally. This is also the reason for the multi-cystic appearance of the ovaries on ultrasound. Two drugs that are used to treat hyperinsulinemia and insulin resistance are Glucophage (Metiformin) and Rezulin (Troglitazone). These drugs can sensitize the cells to the production of insulin and reduce insulin resistance. Glucophage acts primarily on the liver. It blocks the release of glucose by sensitizing the liver to the action of insulin.
Another characteristic of Polycystic Ovarian Syndrome is AUB (abnormal uterine bleeding). This includes anovulation (no ovulation), oligo-ovulation (irregular ovulation), and amenorrhea (the absence of uterine bleeding). With anovulation the ovary does not make the hormone progesterone during the second half of the menstrual cycle. The absence of progesterone causes the lining of the uterus to stay thick (endometrial hyperplasia) and not shed in an efficient manner. This causes amenorrhea. If amenorrhea occurs over a long period of time, a woman may be at an increased risk for uterine cancer. For this reason, patients with PCOS that are not trying to conceive should be treated with medications containing progesterone to induce a normal period at least every two to three months.2
Two of the most prominent characteristics of Polycystic Ovarian Syndrome are infertility and pregnancy loss. The main cause of infertility in patients with PCOS is anovulation. As mentioned before, the follicles in the ovary are stimulated by FSH but there is an insufficient production to fully mature the follicles so they remain and ovulation, nor pregnancy, can occur. PCOS has also been shown to be associated with the increase of LH (lutenizing hormone) levels. Early miscarriage can be caused by this abnormal increase of LH. Eighty two percent of women who have had miscarriages demonstrated polycystic ovaries on ultrasound. For women with PCOS who desire pregnancy, ovulation induction is often necessary. Some drugs that are used as therapy for insulin resistance, such as Glucophage and Rezulin, have been shown to help stimulate ovulation in women with PCOS.3
Obesity, which can also be attributed to one of the causes of Polycystic Ovarian Syndrome, can also increase a women’s chance of developing insulin resistance. The degree of obesity can determine the severity of the insulin resistance and therefore also determine the severity of PCOS. Weight loss, on the other hand, can help reverse the symptoms of PCOS and may alone be enough to stimulate normal ovulation.4 According to the British Journal of radiology, transvaginal ultrasound is the gold standard for the detection of polycystic ovaries. The detection rate of PCOS in young women is about twenty percent. Of the twenty percent, five to ten percent of these patients also demonstrated the classic symptoms of PCOS. The criteria most widely accepted for the identification of PCOS on ultrasound includes: ovaries with ten or more cysts arranged peripherally around an ovary, ovaries that may contain textural changes in the stroma, and ovarian volume of 5.5 cm3 or higher. The use of 3D ultrasound has been useful in measuring ovarian size and volume as well as added to the understanding of hemodynamic changes that could possibly determine the pathological state and progression of the disorder. Clinical criteria can vary but usually includes abnormal labs such as: raised serum concentration of LH, testosterone, 17-OHP (17hydroxyprogesterone), DHEAS and estrone, a form of estrogen. A decrease in FSH is also noted. Other symptoms that classify PCOS are anovulation, amenorrhea, infertility, insulin resistance and hyperandrogenism.
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The use of 3D ultrasound has been useful in measuring ovarian size and volume as well as added to the understanding of hemodynamic changes that could possibly determine the pathological state and progression of the disorder. Clinical criteria can vary but usually includes abnormal labs such as: raised serum concentration of LH, testosterone, 17-OHP (17hydroxyprogesterone), DHEAS and estrone, a form of estrogen. A decrease in FSH is also noted. Other symptoms that classify PCOS are anovulation, amenorrhea, infertility, insulin resistance and hyperandrogenism.
Polycystic Ovarian Syndrome is usually discovered when women visit their doctor’s office with seventy four percent complaining of infertility, sixty six percent complaining of menstrual irregularities, and forty eight percent complaining of the growth of facial or body hair. These complaints are followed up with many combinations of tests including ultrasound and the previously mentioned lab tests.
Polycystic Ovarian Syndrome can cause long term effects which can be briefly described as an increased risk of cardiovascular disease caused by increased lipids or obesity, increased risk of endometrial cancer caused by endometrial hyperplasia, increased risk of breast abnormalities due to the long term exposure to androgens, increased risk of Type II Diabetes due to insulin resistance. These are all clinical observations and are not all directly caused by PCOS.5 Other long term effects of PCOS are psychological problems which can include depression, poor self-esteem, and severe mood swings. This is often caused by the disappointment and struggle that many patients with PCOS face dealing with infertility and the irregular hormones levels that can occur.6
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Conclusion:
Polycystic Ovarian Syndrome with its many complications can cause a lot of stress and discomfort for the patient suffering from this disorder. The psychological issues associated with PCOS are often underestimated and ignored. Therefore, it is important for the sonographer to be able to correctly recognize the signs and symptoms of PCOS so that treatment can be administered as soon as possible. Clinical manifestations including hyperandrogenism, hyperinsulinemia, hirsutism, AUB, amenorrhea, anovulation, and infertility, along with ultrasound demonstration of ovaries containing multiple small follicles along the periphery are the key signs of PCOS. These signs and symptoms have been highlighted in this discussion to enable the sonographer to accurately identify Polycystic Ovarian Syndrome in their patients.
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References:
1. Reproductive Endocrinology and Infertility, Duke University Medical Center, June 3, 2004.
2. Journal of Family Practice, 2005 Feb; 54 (2): 156-60.
3. The British Journal of Radiology 75 (2002), 9-16 The British Institute of Radiology.
4. Obstetrics and Gynecology 2004; 103: 181-1993 by The American College of Obstetricians and
Gynecologists.
5. The Fertility Network: Polycystic Ovarian Disease (PCOS) by Michael D. Scheiber, MD, FACOG,
2002.
6. Journal of Obstetrics and Gynecology and Neonatal Nursing, 2005 Jan-Feb; 34 (1): 12-20.
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Copyright CVTC 2003. All Rights Reserved.