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PCO needs Long Term Follow Up April 2000 Welcome Welcome to the first of a collection of Infertility Case Discussions, which are designed to give you an up-to-date overview of the progress in this area. In this first case, our Consultant discusses the diagnosis and the approach to management of a patient with polycystic ovary disease. The importance of long term follow-up by the family doctor is emphasised. The second and third in this series will be distributed in July and November 2000. Initial Presentation Mary T is a 26 year old woman with an 18 month history of primary infertility. Menarche occured at 14 years of age. She commenced the oral contraceptive pill when she was 18 because of increasingly irregular periods. Since she stopped taking the pill at the age of 22, she has had 3-4 periods a year. She has a normal diet and has a low level of exercise. On examination she is 64kg and has a BMI of 23. She has a slight increase in upper lip hair, but is not otherwise hirsute. She has no galactorrhoea and is clinically euthyroid. Her gynaecological examination and cervical smear test are normal. Sam, her husband, has no significant medical history, has normal testes and a normal semen analysis. Consultant Comment Secondary amenorrhoea is the most likely reason for infertility. The pattern of menstrual irregularity is more typical of polycystic ovary syndrome than it is for hypothalamic amenorrhoea, ovarian failure or hyperprolactinaemia. Hirsutism and obesity are common, but not invariable accompaniments of polycystic ovary syndrome. There is often a family history of hirsutism, irregular menstrual patterns or diabetes. Investigations Investigations are undertaken which return the following results:
Consultant Comments The normal level of FSH excludes premature ovarian failure. In hypothalamic amenorrhoea, gonadotropins are usually low and the oestradiol level is usually lower than 100 pmol/L. Her prolactin level excludes hyperprolactinaemia. The high LH:FSH ratio combined with the raised serum testosterone and low level of SHBG is very typical of the polycystic ovary syndrome. It is unlikely that Mary's cycles will be restored to ovulation by dietary change or exercise since her weight is not excessive. Although tubal occlusion has not been excluded, there is no history supporting this and my approach would be to give Mary treatment to induce ovulation for 3-6 months before considering her for laparoscopy. The relatively high level of testosterone predicts some difficulty at inducing ovulation with clomiphene, but this is the best initial option. Central role of Hyperinsulinaemia The polycystic ovary syndrome (PCOs) is characterised by hyperinsulinaemia, aberrant gonadotropin secretion and excessive androgen secretion by the ovary (and adrenal). The ovaries are generally enlarged and contain increased amounts of androgen-producinginterstitial tissue. Abnormal ovarian stimulation causes activation of large crops of follicles which become arrested at an incomplete level of development. This results in the characteristic peripherally placed cystic appearance of the ovaries. Hyperinsulinaemia in polycystic ovaries is due to an, as yet, unidentified abnormality in insulin-responsive tissues. This post-receptor abnormality is somewhat similar, but not the same as occurs in type 2 diabetes and is the reason why Metformin and other insulin sensitising drugs (Troglitazone etc) have been used to treat PCOs. This hyperinsulinaemia marks this group of patients as being particularly at risk of gestational diabetes during pregnancy, type 2 diabetes in middle age and with premature vascular disease. It is important to follow these issues up (see panel). Hyperinsulinaemia interferes with liver production of sex hormone binding globulin and it increases the activity of a key enzyme responsible for androgen production in the ovary and adrenal. This leads to an increase in testosterone and free testosterone production. Follow-up of PCO syndrome Anovulation/Irregular Periods This exposes the endometrium to unopposed oestrogen. Management: Regular gynaecological checks and smear tests Combined oral contraceptive or Intermittent progesterone 10-14 days each month. Hyperinsulinaemia Increases risk of diabetes and premature heart disease. Management: Encourage regular excercise (30 mins for 3-4 days/week) Maintain ideal body weight Monitor and control other risk factors (lipids, hypertension) Fasting blood sugar annually (RR < 5.5 mmol/L) Monitor glucose early in pregnancy as well as GTT at 28 weeks Consider Metformin or other insulin-sensitising agent Hirsutism Indicates excessive androgen secretion Management: Maintain ideal body weight Combined oral contraceptive Spironolactone Cyproterone acetate References Moghetti P, Castello R, Negri C, Tosi F, Perrone F, Caputo M, Zanolin E and Maggio M. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome. J Clin Endocrinol Metab 2000; 85: 139-146 Hopkinson ZE, Fleming R and Greer IA. Polycystic ovarian syndrome: the metabolic syndrome comes to gynaecology. BMJ 1998; 317: 329-322. More Information Access - National Infertility Support (02) 9670 2380 Oasis - Infertility Support Group (08) 8223 7434 SA Endometriosis Support Group (08) 8267 5366  PRINT THIS PAGE
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