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PolycysticOvarySyndrome:AnOverview
MacPannill,MPAS,PAC
TopicsinAdvancedPracticeNursingeJournal.20022(3)

AbstractandIntroduction
Abstract

Polycysticovarysyndrome(PCOS)isthemostcommonendocrinopathythataffectswomen.PCOSisalsoaleadingcauseof
infertility.WomenwithPCOSmaypresentwithobesity,amenorrhea,oligomenorrhea,infertility,orandrogenicfeatures.Those
withPCOSarealsoatincreasedriskforbothdiabetesanddiabeticcomplicationsandcardiovasculardisease,withariskofa
myocardialinfarction7timesthenormal.WeknowthatifpatientswithPCOSarescreenedforthesediseases,manylongterm
complicationscanbeprevented.
Introduction

PCOSaffects5%to10%ofwomenintheirreproductiveyearsandisthemostcommonendocrinopathyaffectingwomen. [13]
SteinandLeventhal[4]firstdescribedPCOSin1935.OurunderstandingofthepathophysiologyofPCOShasdramatically
changedsincethennow,thereisparticularemphasisonitsrelationshipwithinsulinresistance.PCOSisachronic
hyperandrogenicstatethathasmanysignificantshorttermandlongtermimplicationsforpatientssuchasoligomenorrhea,
amenorrhea,infertility,diabetesmellitus,cardiovasculardisease,increasedriskofendometrialcancer,andexcessivebodyhair
(hirsutism).
PCOSischaracterizedbythefollowing:(1)amenstrualcyclethatrangesfrom>35daysor<8cycles/yeartocomplete
absenceofmenses(amenorrhea)(2)evidenceofandrogenexcess,suchasacne,hirsutism,alopecia,acanthosisnigricans,or
increasedandrogenlevelsonlaboratorytesting(3)allothercausesofhyperandrogenismandanovulationhavebeenexcluded.
[1]Itisnotessentialthatawomanhavepolycysticovariestohavethissyndrome.Therefore,polycysticovaries,observedon
ultrasound,areasignofPCOSandnotbythemselvesdiagnosticofthedisease.Polycysticovariesareseen67%to86%of
thetimeinpatientswhohavePCOS. [1,3,5,6]

Pathophysiology
TheendocrinologicabnormalityofPCOSbeginssoonaftermenarche.Chronicallyelevatedluteinizinghormone(LH)and
insulinresistanceare2ofthemostcommonendocrineaberrationsseeninPCOS.ThegeneticcauseofhighLHisnotknown.
ItisinterestingtonotethatneitheranelevationinLHnorinsulinresistancealoneisenoughtoexplainthepathogenesisof
PCOS. [79]InvitroandinvivoevidenceoffersupportthathighLHandhyperinsulinemiaworksynergistically,causingovarian
growth,androgenproduction,andovariancystformation.
Obesity,whichisseenin50%to65%ofPCOSpatients,mayincreasetheinsulinresistanceandhyperinsulinemia.One
importantcaveatisthatthecorrelationbetweenhyperandrogenismandinsulinresistancehasbeenrecognizedinbothobese
andnonobeseanovulatorywomen.Thus,itisimportanttorealizethatanonobesepatientmayalsohaveinsulinresistance.
However,theinsulinlevelsinobesewomenarehigherthantheirnonobesecounterparts.Clinically,though,bothgroupswill
haveevidenceofhyperandrogenismandoligoovulationoranovulation. [6,7]
Insulinresistancecanbecharacterizedasimpairedactionofinsulinintheuptakeandmetabolismofglucose. [6]Impaired
insulinactionleadstoelevatedinsulinlevels,whichcausesadecreaseinthesynthesisof2importantbindingproteins:insulin
likegrowthfactorbindingprotein(IGFBPI)andsexhormonebindingglobulin(SHBG).IGFBPIbindstoIGFBPIIandSHBG
bindstosexsteroids,especiallyandrogens.Thetriadofhyperandrogenism,insulinresistance,andacanthosisnigricans(HAIR
AN)syndromeappearsinasubgroupofpatientswithPCOS. [6,10,11]
Acanthosisnigricans,adarkandhyperpigmentedhyperplasiaoftheskintypicallyfoundatthenapeoftheneckandaxilla,isa
markerforinsulinresistance.Acanthosisnigricansisusuallyfoundinabout30%ofhyperandrogenicwomen.Figure1
illustratesacanthosisnigricansevidentinapatient'saxilla.
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Figure1.

Acanthosisnigricansinapatient'saxilla.PhotocourtesyofStanfordLamberg,MD,AssociateProfessor,Dermatology,The
JohnsHopkinsMedicalInstitutions,Baltimore,Maryland.
RelationshipBetweenDiabetesMellitusandPCOS

WomenwithPCOSareathigherriskofdevelopingdiabetesmellitustype2becauseoftherelativeinsulinresistance.Also,
thesewomentendtodevelopdiabetesearlierinlife,aroundthethirdorfourthdecade.Itisgenerallyrecommended,because
oftheknownlongtermcomplicationsofdiabetes,thattheseyoungwomenbetestedearlyinlifeandfollowedclosely.These
womenshouldbescreenedinearlypregnancy,astheyhaveanincreasedriskofdevelopinggestationaldiabetes. [2,5,12]
RelationshipofCardiovascularDiseasetoPCOS

Womenwhoarehyperandrogenicandhyperinsulinemicareatincreasedriskfordyslipidemia,coronaryarterydisease,
hypertension,anddiabetesmellitus.ThemostcommonlipidabnormalitiesfoundinobesePCOSpatientsaredecreasedhigh
densitylipoproteinandelevatedtriglycerides.InadditiontothelipidabnormalitiesseeninwomenwithPCOS,thesepatients
are7timesmorelikelytohaveamyocardialinfarction. [3,13]Becausecardiovasculardiseaseistheleadingcauseofdeathof
amongwomen,preventionisessential.

AssessmentofthePCOSPatient
History

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Inadditiontoobtainingathoroughmedicalandsurgicalhistory,elicitacompletedmenstrualhistory,includingmenarcheand
familyhistoryofPCOS.Ahistoryofhirsutism,acne,alopecia,menstrualirregularities,orinfertility,especiallyinthepatient's
mother,isveryimportant.AdiagnosisofPCOSmayoftenbemadewithacompletehistory.Payparticularattentiontothe
onsetofmenstrualirregularities,asthiswillusuallydatebacktomenarche.Inquireaboutrecentpregnancystatusandother
reproductivehistorysuchasmiscarriages.
Medicalhistory.Ahistoryofheadachesorblurredvision(indicatingpituitarytumor),anysignsorsymptomsofthyroid
dysfunction(asadifferentialdiagnosisofamenorrhea),orclinicalsignsofdiabetes(indicatingadrenaltumor)needtobe
elicited.Inquireaboutahistoryofacne,hirsutism,deepeningofthevoice,andincreaseinmusclemass(withoutexercise).If
thesesymptomshaveoccurred,whathasbeentriedtocontrolthem?Itisimperativetoknowifthesymptomsarerecentor
haveoccurredrapidly,eitherofwhichcouldindicateavirilizingsyndromeorneoplasia.Arapidonsetofthesesymptomsisrare
inaPCOSpatient,butifpresent,theysuggestaneedforanurgentworkup,asanovariantumororadrenaltumorneedsto
beruledout.Also,masculinizationisuncommonwithPCOSpatientsandismoresuggestiveofcongenitaladrenalhyperplasia.
Familyhistory.PCOStendstoruninfamiliesitisimportanttoaskaboutfamilyhistory.Somebelievethatifamotherhas
PCOSandherdaughterisshowingsignsofit,sheshouldbeevaluatedbyherpediatricianorbyanendocrinologist. [14]
Social/culturalhistory.Ethnicfactorsmustbeconsideredintheevaluationofwomenwhoarehirsute.NorthernEuropean
whitewomenandwomenfromAsiausuallyhavesmallamountsofhairontheirface,torso,andextremities.However,
Mediterraneanwhitewomenwillfrequentlyhavehairontheirupperlip,chin,andhavedarkhairontheirarmsandlegs.Also,
certainconditionslikepregnancyandmenopausecancausetransienthirsutism.Animportantcaveattorememberisthe
patientmaynotappearhirsuteatthetimeoftheexaminationasshemaybeusingcosmeticprocedureslikewaxing,shaving,
orelectrolysistocontrolit.
Medications.Inadditiontoaskingaboutthepatient'scurrentmedicationsitisimportanttorememberthattherearecertain
medicationsandclassesofmedicationsthatcancausetransienthirsutism.Examplesofthesearephenytoin(Dilantin),
diazoxide,glucocorticoids,andthephenothiazines. [1,9,15,16]
ClinicalFeatures

Evaluatetheskinforevidenceofhirsutism,acne,alopecia,fatdistribution,andpigmentchangesintheskin,specifically
acanthosisnigricans.Hirsutismcanbedefinedashairinlocationsinwomenwhereitisusuallynotfound.Examplesofthese
locationsareupperlip,chin,midlineofthebody,andintheintermammaryregion.Hirsutismcanbegradedusingthe
FerrimanGalloweyscoringsystem(Figure2).Thisscoringsystemevaluates9keyanatomicsites.Thesesitescanbegraded
from0(noterminalhairgrowth)to4(maximalgrowth).Themaximumscoreis36.Ascoreof8orgreatersuggestsan
androgenexcess. [1,9,15]

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FerrimanGalloweyscoringsystemforhirsutism.ReproducedwithpermissionofpublisherfromBarbieriRL:VPolycysticOvary
Syndrome.16Women'sHealth.WebMDScientificAmericanMedicineOnline.DaleDC,FedermanDD,Eds.WebMD
Corporation,NewYork,2002.http://www.samed.com
EvenwhenaPCOSpatienthasincreasedlevelsofandrogens,hirsutismmaynotbepresentunlessthereisanincreasein
peripheralandrogenmetabolism.ThisiswhysomewomenwithPCOSarehirsuteandothersarenot.Temporalbaldingis
usuallyseenafterprolongedexposuretoandrogens.Frontalbaldingisassociatedwithavirilizingovarianoradrenaltumor.
Centralobesitywithahipratioof>0.85isassociatedwithcardiovasculardiseaseandisamarkerforPCOS.A"buffalohump"
onthebackorpurplestriaeontheabdomenmightsuggestCushing'ssyndrome.
Duringthepelvicexamination,assessforclitoromegalyandpelvicmasses.Bilateralpelvicmasseswouldbemoreconsistent
withPCOSwhereasaunilateralpelvicmassmaybemoreconsistentwithaneoplasia.Remember,too,thatthepelvicexam
maynotrevealanymassesinapatientwithPCOS.
LaboratoryStudies

Theresultsofthehistory,inconcertwiththephysicalexamination,willguidethelaboratoryworkup().Thistestingis
designedtoexcludelifethreateningtumorsandpromotelongtermhealth.
Table1.LaboratoryStudies

LH
FSH
TSH
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Prolactin
Lipidpanel(cholesterol,HDL,LDL,andtriglycerides)
Fastinginsulinlevel
2hour75gglucosetolerancetest
DHEAS
Testosterone
Freetestosterone
17Hydroxyprogesterone

LH,luteinizinghormoneFSH,folliclestimulatinghormoneTSH,thyroidstimulatinghormoneHDL,highdensitylipoprotein
LDL,lowdensitylipoproteinDHEAS,dehydroepiandrosteronesulfate
Endocrinescreening.Prolactinandthyroidstimulatinghormone(TSH)levelsaretestedtoruleoutpituitaryorthyroid
diseaseasanetiologyofanovulation.LHandfolliclestimulatinghormone(FSH)maybeanalyzed,andtheyareusuallyseen
inaratioof>2.5to3.However,anormalLH/FSHratiodoesnotexcludethediagnosisofPCOS.AnFSHlevelwillalsohelp
ruleoutprematureovarianfailureinawomanwithamenorrhea. [1,6,9,15]
Totaltestosteroneanddehydroepiandrosteronesulfate(DHEAS)areevaluatedtoruleoutanandrogenproducingneoplasm.
Totaltestosteronelevelsof200ng/dLarenotgenerallyseeninPCOSandsuggestavirilizingtumor.DHEASisaweak
androgenthatprimarilycomesfromtheadrenalglands.Alevelgreaterthan800mcg/dLsuggestsavirilizingadrenaltumor.
17hydroxyprogesterone(17OHprogesterone)isausefulscreenforlateonsetcongenitaladrenalhyperplasia(LOCAD).17OH
progesteronelevelslessthan2ng/mLarenormal.Alevel>5ng/mLisdiagnosticforLOCAD.Avaluebetween2ng/mLand5
ng/mLshouldpromptaninvestigationwithanadrenocorticotropichormonestimulationtest.IfthereisasuspicionforCushing's
syndrome,youmaygeta24hoururineforfreecortisolordoa1mgdexamethasonesuppressiontestovernight.
Cardiacriskprofile.BecausePCOSpatientshavehyperandrogenism,theyareatanincreasedriskofcardiovasculardisease.
Itisimperative,then,thatthepatientsarescreenedforanabnormalHDL,cholesterol,andtriglyceridesat35yearsofage.
Normalresultsshouldberepeatedin35years.Iftheseresultsareabnormal,theseentitiescanbetreatedearly,thusreducing
theriskofcardiovasculardisease.
Glucosetesting.Glucosetolerancetestingisimportant.Asmanyas35%to45%ofPCOSpatientswillhaveimpaired
glucosetestingandabout7%to10%willhavetype2diabetesmellitus.Afastingglucosetofastinginsulinratiolessthan4.5
ispredictiveofinsulinresistance.Valuesonthe2HRglucosetolerancetestareasfollows:2H<140mg/dL(normal)140199
mg/dl(impairedglucose)and>200mg/dL(type2diabetes). [13,17]
EndometrialAspiration

ManyPCOSpatientshaveunopposedestrogenstimulationforprolongedperiodsoftimeandarethusatriskforendometrial
hyperplasiaorendometrialcarcinoma.AnyPCOSpatientwithprolongedoligomenorrheaoramenorrheaorapatientwith
PCOSwhoisolderthanaged35yearsandhasirregularbleedingshouldhaveendometrialaspirationtoruleoutendometrial
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carcinoma.Animportantpointtorememberisthatadvancingageisnotafactorindecidingtoobtainendometrialaspirationin
patientswithPCOSasitisinnonPCOSpatients.
RadiologicStudies

Anenlargeduterusorenlargedovariespalpatedonpelvicexaminationsuggestsaneedforapelvicultrasoundtodistinguish
uterinefibroidsfromanadnexalmass.IfapatienthaselevatedDHEAS,adrenalimagingisindicated.Animportantcaveatto
rememberisthatpolycysticovariescanbeenseeninanumberofhealthywomenwhodonothavePCOS,andwomenwith
PCOSdonotalwayshaveradiographicallydemonstratedpolycysticovaries.Remember,byultrasound,25%of"normal"
ovulatingwomenwouldhavepolycysticappearingovaries. [5,6,9,18]
Atransvaginalultrasoundshouldbedone,as90%ofvirilizingtumorscanbeidentifiedwiththismethod.Polycysticovariesare
alsobetterevaluatedtransvaginallythantransabdominally.Ovarieswillhaveatypicalappearanceofenlargedsubcapsular
smallfollicles(>10mm)folliclesarenormally2mmto10mmindiameter.TheovarianvolumeinwomenwithPCOSis>
10cm3andthenormalrangeis4.75.2cm3.

DifferentialDiagnosis
Prematureovarianfailure,rapidweightloss,extremephysicalexertion,lowbodymassindex(BMI)asinanorexianervosa,and
pregnancywillcauseabnormalmenstrualcycles().Discontinuationoforalcontraceptivesmayalsocauseamenorrhea.The
latteriscalledpostpillamenorrhea.Apituitaryadenoma,hyperthyroidism,orhypothyroidismwillalsocauseachangeinthe
menstrualcycle.
Table2.DifferentialDiagnosesinPolycysticOvaries

Pregnancy
Prematureovarianfailure
Hyperthyroidism
Hypothyroidism
Pituitaryadenoma
Lateonsetcongenitaladrenalhyperplasia
Congenitaladrenalhyperplasia
Androgenproducingtumoroftheovaryoradrenalgland
Discontinuationoforalcontraceptives
Rapidweightloss
Extremephysicalexertion

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Otherimportantetiologiestoconsiderincludecongenitaladrenalhyperplasia,lateonsetadrenalhyperplasia,andCushing's
syndrome.Tumorsoftheadrenalglandortheovariesmayalsopresentwithmenstrualirregularities. [8,9,16]

TreatmentOptions
WeightLoss

WomenwithaBMIofgreaterthan27kg/m2areconsideredoverweight,andtheyareofteninsulinresistant.Womenwitha
BMIof>30kg/m2areconsideredobeseandarealmostalwaysinsulinresistant.Weightloss,evenasalittleas5%to7%,can
decreasetheamountofcirculatingandrogensand,thus,willinduceovulation.Weightlossisalsoassociatedwithdecreased
insulinandtestosteronelevelsandanimprovedlipoproteinprofile.Thesepatientsusuallydothebestwhenmanymembersof
ahealthcareteam,includinganutritionist,areactivelyinvolvedintheircare. [1,3,8]
HormonalTreatments

Combinationoralcontraceptives(OCs)providemanybenefitstothePCOSpatientandhaveforalongtimebeenthemainstay
oftreatment.TheprogesteronecomponentoftheOCprovidesprotectionfortheendometriumfromunopposedestrogen.Also,
OCssuppressovarian,adrenal,andperipheralandrogenmetabolism,whichinturnsreducesfreetestosterone.OCsalso
suppressLHlevels,whichthendecreasetestosteroneproductionbytheovaries.Similarly,OCsinhibit5alphareductaseinthe
skin,whichhelpswithacne.Forthosepatientsnotwantingtobecomepregnant,OCsprovideareliableformofbirthcontrolin
additiontoprovidingaregularmonthlymenstrualcycle.
TherearenostudiesthatsuggestthatoneOCisbetterthananotherforthetreatmentofPCOS.AllOCs,whethertheycarry
anFDAindication,areantiandrogenic.Onceapatienthasdecidedthatshewantstotryandconceive,sheshouldthenstop
herOCsandpromptlybeginattemptstoconceive.Thereisnoneedtowaitthetraditional3monthsbeforeattemptinga
pregnancy.ThisisimportantbecausecirculatingandrogensareattheirlowestpointimmediatelyfollowingOCuse,andthese
patientswillmorelikelyovulateatthattimeandnotrequireanovulationinductiondrug. [1,9,19]
ProgestinsworkwellinthepatientwhoisnotacandidateforOCsduetosmoking,hypertension,orothercontraindications.
Theprogestinwillprotecttheendometriumfromchronicexposuretoestrogen.Theprogestins,however,willnotprotect
againstapregnancy. [6,9]
InsulinSensitizingAgents

Metformin(Glucophage)andtroglitazone(Rezulin)are2insulinsensitizingagentsthathavebeenshowntobesuccessfulin
treatinganovulationintheinfertilePCOSpatient.However,becauseofreportsofseverelivertoxicity,troglitazonewas
removedfromthemarket,sometforminisnowtheinsulinsensitizingagentofchoice.Theneweragentsonthemarket,
rosiglitazone(Avandia)andpioglitazone(Actos),havenotbeenextensivelystudied.
Insulinsensitizingagentsareindicatedinpatientswithtype2diabetesmellitus,elevatedfastinginsulinlevels,orelevated2
hourvalueontheglucosetolerancetest.Metformin15002000mgperdayin2to3divideddosesisprescribedtostimulate
resumptionofnormalmensesandovulation.Generally,ittakesabout2to4monthsforresults.Priortostartingmetformin,
serumcreatininelevelsshouldbeevaluated.Levelslessthan1.4mg/dLarenecessarytoreducetherarecomplicationoflactic
acidosis. [1,3,8]
SincefewstudiesreporttheuseofinsulinsensitizingagentsinPCOSpatientswhodonothaveinsulinresistance,theiruseis
notindicated.However,intime,theseagentsmaybeusedtotreatallpatientswithPCOS. [1,3,8]
FertilityTherapy

Clomiphene(Clomid)maybeprescribedforPCOSpatientswhoareanovulatoryanddesirepregnancy.Oncethepatienthas
conceived,clomipheneshouldbediscontinued.Ifthepatientwastakingmetformin,itshouldalsobediscontinued,asitisnot
FDAapprovedforuseduringpregnancy. [1,3,8]
TreatmentofHirsutism

Therearemanyantiandrogenicagentsthatworkwelltoreducehirsutism.Oralcontraceptivesworkwellbecausetheyincrease
SHBG,whichresultsinlowerlevelsofactiveandrogens.Also,theprogestincomponentintheOCsinhibit5alphareductasein
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theskin,whichhelpsdecreasetheamountofhirsutism.
Spironolactoneisanaldosteroneantagonistthatworkswelltocontrolhirsutismbyinterferingwithandrogensynthesis.The
recommendeddoseofspironolactoneis100200mg/dayin2divideddoses.Therearefewsideeffectsassociatedwiththis
drug.However,becauseitisapotassiumsparingdiuretic,beawareofthepotentialforhyperkalemiawithprolongeduse.
Flutamide(Eulexin)andfinasteride(Proscar)areotherantiandrogenicdrugs.Theyarecostlyandhavemanysideeffects,thus
makingthemlessappealingoptions.Thelengthofthehaircycleislong,sotheresponseofthesedrugsshouldnotbe
expectedforatleast36months.Thisisanimportantpointtostresstothepatient.
Nonpharmacologictreatmentsforhirsutismmayincludebleaching,waxstripping,shaving,ortheuseofhairremovalcreamsor
electrolysis.Despitepopularbeliefs,theseapproachesdonotacceleratetherateofhairgrowth. [1,9]
SurgicalTreatment

OvarianwedgeresectionisasurgicalprocedurethatwasoncedoneforpatientswithPCOS.Inthisprocedure,aportionofthe
ovarywasremovedandtheremainderoftheovarywassuturedbacktogether.ThiscausedareductioninLHsecretionand
androgenproduction.However,duethesevereadhesivediseasethatensued,thisprocedurehasallbutbeenabandoned.
Ovariandrillingmaysometimesbeusedbecausethereismuchlessadhesionformationfollowingthisprocedure.Ovarian
drillingisanothersurgicalprocedurethatinvolvescauterizingthesmallfolliclesonthesurfaceoftheovary.Bycauterizing
thesefollicles,androgenproductionwillbedecreased. [9]

CasePresentation
Barbaraisa25yearoldmorbidlyobeseAfricanAmericanfemale,gravida0,whopresentedtothegynecologyofficefor
evaluationofirregularmensessincemenarche.Thepatientstatedthatonaverage,shehas1periodevery6months.When
shedoeshaveherperiod,shebleedsveryheavily,passinglargeclots,andhasalotofcramping.Shealsocomplainedabout
excessivefacialhair,whichrequireshertoshaveatleastonceeveryseveraldays,andalotofhaironherabdomenandarms.
Barbarastatedthathermotheralsohasalotoffacialhairbutdoesn'tthinkthatshedoesanythingaboutit.
Shedeniedanychangeinhervoiceorincreaseinthesizeofhermuscles.Shehasbeenmorbidlyobesesinceshewasa
youngteenager.Shedeniedanyheadaches,blurredvision,ordischargefromhernipples.Shealsodeniedany
hyper/hypothyroidsymptoms.Shehasneverhadanysurgeryandhasneverconceived,despiteseveralyearsoftrying.Barbara
isnotcurrentlytakinganymedicationandhasneverusedanyformofcontraception.
Onexamination,shewasclearlyhirsute(FerrimanGalloweyscoreof10),especiallyinthechinandmidabdominalregions.Her
BMIwas32.Herpelvicexamwasunremarkable,includingnoevidenceforclitoromegaly,butheruterusandadnexawerevery
difficulttoassesssecondarytothepatient'smorbidobesity.Therestofherphysicalexamwasunremarkable.Becauseshehad
beenamenorrheicfor6months,anendometrialaspirationwasperformed.Theuterussoundedto8cmandtherewasagood
amountoftissueonreturn.
Auterineultrasoundwasperformed,whichrevealedanormalappearinguterus,withanendometrialstripeof6mmand
bilateralnormalovaries.Specifically,therewasnoevidenceforpolycysticovaries.
Laboratorystudieswereundertakentofurtherevaluateherproblem.HerFSHwasnormal,butherLHwaselevated.HerTSH,
prolactin,chemistrypanel,cholesterol,triglycerides,HDL,andlowdensitylipoprotein(LDL)wereallwithinnormallimits.Her
fastinginsulinlevelwaselevatedat36UU/mLfastingbloodsugarwas130mg/dL,andthe2hourvalueonglucosetolerance
testwas233mg/dL.Hertotaltestosteronewas78ng/dL,andherfreetestosteronewas30pg/mL(normalrange,121pg/mL.)
Her17OHprogesteronewasnormalat92ng/dL,aswastheDHEASat131ug/dL.Theendometrialaspirateshowed
proliferativeendometriumwithouthyperplasiaorneoplasia.
TheclinicalandlaboratoryresultswereconsistentwithPCOS.Becauseshedesiredapregnancy,shewasacandidatefor
metforminnotonlyforcontrolofherbloodsugarbutalsotohelpregulatehermenstrualcycles.Shealsorequiredclomiphene
toinduceovulation.Afterbeingstartedonadiet,anexerciseprogramforweightloss,andmetformin,herbloodsugars
respondedwell.After6monthsofbloodglucosecontrol,menstrualregularity,andincreasingdosesofclomiphene,she
becamepregnant.Today,BarbaraisdoingwellinourhighriskOBpractice.
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Conclusion
PCOSismuchmorethanjustoligomenorrhea,amenorrhea,orinfertility.PCOSencompassesmanylongtermhealth
problemssuchasthedevelopmentofcardiovasculardisease,type2diabetesmellitus,andprolongedexposuretounopposed
estrogen,whichcanleadtoendometrialhyperplasiaandendometrialcarcinoma.Cliniciansneedtobeawareoftheriskfactors
forPCOSandintervenewithapreventiveapproach,whichmayrestorenormalmenstrualfunction,ovulation,andfertilityfor
thosedesiringit.WecanalsopreventorlimitthecomplicationsfromwhichPCOSpatientssuffer,suchascardiovascular
disease,diabetesmellitus,andincreasedriskforunopposedestrogen.
Disclosure

MacPannill,MPAS,PAC,hasnosignificantfinancialintereststodisclose.
ClinicalArticlesMEDLINEAbstracts:PolycysticOvarySyndrome
ConferenceCoverage4thAnnualConferenceoftheNationalAssociationofNursePractitionersinWomen'sHealth
11thAnnualMeetingandClinicalCongressoftheAmericanAssociationofClinicalEndocrinologists
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