Overview
Definition
A heterogeneous endocrine disorder characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries.
Epidemiology
The most common endocrine abnormality in women of reproductive age (affecting up to 15%).
Etiology & Risk Factors
- Complex genetic trait interacting with environmental factors (obesity). Underlying insulin resistance leads to compensatory hyperinsulinemia, which stimulates ovarian theca cells to produce excess androgens (testosterone) and alters GnRH pulsatility (increasing LH).
Clinical Symptoms
- Oligo-ovulation or Anovulation (irregular or absent periods)
- Hyperandrogenism: Hirsutism (excess facial/body hair), severe acne, male-pattern alopecia
- Metabolic syndrome features: Obesity, Acanthosis nigricans (dark, velvety skin patches indicating insulin resistance)
Clinical Approach
Diagnosis
- Rotterdam Criteria (requires 2 out of 3): (1) Oligo/anovulation, (2) Clinical or biochemical signs of hyperandrogenism, (3) Polycystic ovaries on ultrasound (≥ 12 follicles per ovary or increased ovarian volume)
- Labs: Elevated LH/FSH ratio (> 2:1), elevated testosterone. Must rule out congenital adrenal hyperplasia, Cushing's, and prolactinoma.
Management
- Lifestyle: Weight loss and exercise (first-line, significantly improves insulin resistance and ovulation)
- Menstrual regulation & Hirsutism: Combined Oral Contraceptives (OCPs)
- Insulin Resistance: Metformin
- Infertility: Letrozole (aromatase inhibitor) or Clomiphene to induce ovulation
- Hirsutism (refractory): Spironolactone (must use with OCPs due to teratogenicity)
Complications
- Endometrial hyperplasia and Endometrial Cancer (due to unopposed estrogen from chronic anovulation)
- Type 2 Diabetes
- Cardiovascular disease
- Infertility
- Obstructive Sleep Apnea