PCOD || Gynecology

Summary

This lecture covers polycystic ovarian syndrome (PCOS), detailing its pathology rooted in increased androgen production leading to hirsutism and hormonal imbalances. It explains how elevated estrogen negatively impacts follicle-stimulating hormone, disrupts ovulation, and causes endometrial issues. The talk also addresses PCOS's link to insulin resistance, cardiovascular risks, and potential cancers. The Rotterdam criteria for diagnosis and treatment options, including lifestyle changes, medications, and surgery, are also discussed.

Takeaways

• 🌟 Polycystic Ovarian Syndrome (PCOS) is also known as Stein-Leventhal Syndrome and is characterized by increased androgen production.
• 🔬 The excess androgens lead to hirsutism (excessive hair growth) and are converted to estrogens by the aromatase enzyme, causing a cascade of hormonal imbalances.
• 📉 High estrogen levels decrease follicle-stimulating hormone (FSH) and increase luteinizing hormone (LH), resulting in an altered LH to FSH ratio, typically more than 2:1 in PCOS.
• 🚫 The lack of a LH surge, which is necessary for ovulation, leads to oligomenorrhea or amenorrhea, and eventually, multiple cysts in the ovaries.
• ⚠️ Increased LH stimulates theca cells to produce more androgens, perpetuating the cycle and contributing to the thickening of ovarian tissue.
• 🌡 Unopposed estrogen can lead to endometrial hyperplasia, which may progress to cancer, and PCOS patients are at higher risk for endometrial and breast cancers.
• 🏃‍♀️ Lifestyle modifications and weight reduction are the first-line treatments for PCOS, aiming to reduce obesity and improve insulin resistance.
• 💊 Oral contraceptive pills (OCPs) are often prescribed to regulate menstrual cycles and manage hirsutism in PCOS patients.
• 🩺 Metformin is used to address insulin resistance, a common comorbidity in PCOS that can lead to type 2 diabetes.
• 🏥 Infertility in PCOS may be treated with selective estrogen receptor modulators like clomiphene citrate, with gonadotropins or LH/FSH injections as second-line options.

Q & A

What is Polycystic Ovarian Disease (PCOS) also known as?

Polycystic Ovarian Disease (PCOS) is also known as Polycystic Ovarian Syndrome and Stein-Leventhal Syndrome.

What is the basic pathology behind Stein-Leventhal Syndrome?

The basic pathology in Stein-Leventhal Syndrome is increased androgen production, which leads to various symptoms such as hirsutism.

How does increased androgen production lead to hirsutism?

Increased androgen production stimulates the growth of sexual terminal hair, resulting in hirsutism.

What is the role of the aromatase enzyme in the context of PCOS?

The aromatase enzyme converts androgen to estrogen, which has several effects including decreasing follicle stimulating hormone (FSH).

Why does increased estrogen lead to a decrease in FSH?

Increased estrogen exerts a negative feedback mechanism on FSH, as estrogen is produced by the ovaries in response to FSH stimulation from the pituitary gland.

What is the significance of the LH to FSH ratio in patients with PCOS?

In patients with PCOS, the LH to FSH ratio is more than 2:1, indicating an imbalance in these hormones.

How does the absence of an LH surge affect ovulation in PCOS?

The absence of an LH surge, which is necessary for ovulation, leads to a lack of ovulation in PCOS.

What are the long-term consequences of PCOS on a woman's health?

Long-term consequences of PCOS include increased cardiovascular risk factors, risk of diabetes mellitus due to insulin resistance, and increased risk of endometrial and breast carcinomas.

What is acanthosis nigricans and how is it related to PCOS?

Acanthosis nigricans is a condition characterized by pigmented, velvety skin, often in the neck and axilla areas, and it is related to insulin resistance, which is common in PCOS.

What are the Rotterdam criteria for diagnosing PCOS?

The Rotterdam criteria for diagnosing PCOS include the presence of oligomenorrhea or amenorrhea, clinical and biochemical symptoms such as hirsutism and increased serum testosterone, and the presence of 12 or more cysts in the ovaries on ultrasonography.

What is the first line of treatment for PCOS?

The first line of treatment for PCOS is weight reduction and lifestyle modifications. If necessary, treatment may also include oral contraceptive pills (OCPs) for irregular periods and metformin for insulin resistance.

What are the treatment options for infertility in PCOS?

For infertility associated with PCOS, the first line of treatment includes selective estrogen receptor modulators such as clomiphene citrate. Second line treatments may include gonadotropins or LH/FSH injections, and third line treatments may involve the use of GnRH analogs.

Outlines

00:00

🌟 Understanding Polycystic Ovarian Disease (PCOS)

This paragraph introduces Polycystic Ovarian Disease (PCOS), also known as Stein-Leventhal Syndrome, highlighting the key pathology of increased androgen production. It explains how this leads to hirsutism due to androgen stimulation of sexual terminal hair growth. The androgen is then converted to estrogen by the aromatase enzyme, which has three main effects: decreasing follicle-stimulating hormone (FSH), altering the ratio of luteinizing hormone (LH) to FSH, and causing continuous LH increase without an LH surge, preventing ovulation. This results in decreased progesterone levels, leading to oligomenorrhea and potentially secondary amenorrhea. The paragraph also discusses the impact of LH on the theca cells, causing them to produce more androgens.

05:01

🌱 Complications and Clinical Features of PCOS

The second paragraph delves into the complications of PCOS, including the formation of multiple cysts in the ovaries due to the lack of a dominant follicle and ovulation. It explains how increased androgens lead to higher estrogen levels, which can cause endometrial hyperplasia and potentially endometrial cancer and breast carcinoma. The paragraph also addresses the impact of PCOS on lipid profiles, leading to increased LDL and decreased HDL, which raises cardiovascular risks. It mentions insulin resistance caused by increased androgens inhibiting sex hormone-binding globulin, predisposing patients to diabetes mellitus. Additionally, it covers the psychological effects of PCOS, such as obesity leading to mood changes, depression, and sleep apnea. Clinical features include menstrual irregularity, obesity, hirsutism, acne, alopecia, altered lipid profiles, and insulin resistance.

10:02

🔍 Hormonal Changes and Diagnostic Criteria for PCOS

This paragraph discusses the hormonal changes in PCOS, including increased androgens like testosterone, androstenedione, and DHEA, as well as increased LH and estrogen. It also points out the presence of insulin resistance, high insulin levels, and increased LDL cholesterol. The diagnostic criteria for PCOS, known as the Rotterdam Criteria, are outlined, which include the presence of oligomenorrhea or amenorrhea, clinical symptoms like hirsutism, and biochemical symptoms such as elevated serum testosterone levels. The criteria also involve the ultrasound detection of 12 or more cysts in the ovaries, each 2-9 mm in size, with enlarged ovaries over 10 ml in volume.

15:03

💊 Treatment Approaches for PCOS

The fourth paragraph focuses on the treatment of PCOS, starting with weight reduction and lifestyle modifications as the first line of treatment. It mentions the use of oral contraceptive pills (OCPs) for managing irregular periods and metformin for insulin resistance. For hirsutism, a combination of OCPs with ciproteron acetate is suggested. The paragraph also outlines the treatment for infertility associated with PCOS, which involves selective estrogen receptor modulators like clomiphene citrate, tamoxifen, and reloxifen. It discusses the use of second-line treatments such as gonadotropins or LH/FSH injections and third-line treatments like leuprolide or ganirelix, which are GnRH analogs. In cases where medical treatments fail, laparoscopic ovarian drilling is considered as a surgical option.

20:04

🛠 Surgical Intervention and Conclusion

The final paragraph briefly touches on the surgical intervention for PCOS, specifically laparoscopic ovarian drilling, which involves the destruction of ovarian theca cells using a monopolar cautery to reduce the number of cysts. The paragraph concludes the lecture by summarizing the key points about PCOS and thanking the audience for their attention.

Keywords

💡Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS) is a hormonal disorder common among women of reproductive age. It is characterized by the presence of multiple cysts in the ovaries, which can lead to irregular menstrual periods, infertility, and increased androgen levels. In the video, PCOS is discussed as the main theme, with an emphasis on its effects on hormone levels, menstrual cycle, and long-term health implications.

💡Androgens

Androgens are a group of hormones that include testosterone and are responsible for the development of male characteristics. In the context of the video, increased androgen production is a key feature of PCOS, leading to symptoms such as hirsutism (excessive hair growth). The video explains how increased androgens can stimulate the growth of sexual terminal hair, resulting in hirsutism.

💡Hirsutism

Hirsutism refers to the excessive growth of hair in areas of the body where hair growth is typically associated with males, such as the face, chest, and back. The video discusses how increased androgen levels in PCOS patients can lead to hirsutism, which is a common symptom that affects the quality of life for many women with the condition.

💡Aromatase Enzyme

The aromatase enzyme is involved in the conversion of androgens to estrogens in the body. The video explains that in PCOS, increased androgens are converted to estrogens by the aromatase enzyme, which can lead to a series of hormonal imbalances and contribute to the development of PCOS symptoms.

💡Follicle Stimulating Hormone (FSH)

Follicle Stimulating Hormone is a gonadotropin that stimulates the growth of ovarian follicles in women. The video describes how increased estrogen levels in PCOS can lead to a decrease in FSH, which in turn affects the normal development and ovulation of ovarian follicles.

💡Luteinizing Hormone (LH)

Luteinizing Hormone is another gonadotropin that triggers ovulation and the production of testosterone in women. The video highlights that in PCOS, there is often an imbalance in the ratio of LH to FSH, with higher levels of LH contributing to the condition's symptoms.

💡Ovulation

Ovulation is the release of an egg from the ovary, which is a necessary process for fertility. The video explains that one of the key issues in PCOS is the absence of a normal LH surge, leading to a lack of ovulation and resulting in infertility or irregular menstrual cycles.

💡Endometrial Hyperplasia

Endometrial hyperplasia is a condition where the lining of the uterus (endometrium) becomes excessively thick. The video discusses how the increased estrogen levels in PCOS can lead to endometrial hyperplasia, which over time can progress to more severe conditions, including endometrial cancer.

💡Insulin Resistance

Insulin resistance is a condition in which the body's cells do not respond properly to the hormone insulin, leading to high blood sugar levels. The video explains that increased androgens in PCOS can inhibit the production of sex hormone-binding globulin, resulting in increased insulin levels and insulin resistance, which can predispose patients to type 2 diabetes.

💡Rotterdam Criteria

The Rotterdam Criteria are a set of guidelines used to diagnose PCOS. The video mentions these criteria, which include the presence of oligomenorrhea or amenorrhea, clinical and biochemical signs of hyperandrogenism, and polycystic ovaries observed through ultrasound. These criteria help healthcare providers to accurately diagnose and treat PCOS.

Highlights

Polycystic ovarian disease (PCOD) is also known as polycystic ovarian syndrome or Stein-Leventhal syndrome.

Increased androgen production is the basic pathology in PCOD.

Androgen increase leads to hirsutism, the growth of sexual terminal hair.

Androgen is converted to estrogen by the aromatase enzyme, impacting follicle stimulating hormone (FSH) levels.

Elevated estrogen decreases FSH and increases the ratio of luteinizing hormone (LH) to FSH, which is typically greater than 2:1 in PCOD.

The absence of an LH surge due to constant LH increase prevents ovulation.

No ovulation results in decreased progesterone levels, leading to oligomenorrhea and potentially secondary amenorrhea.

Increased LH stimulates theca cells, causing hypertrophy and further androgen production.

In PCOD, multiple follicles form but do not mature into a corpus luteum, leading to cysts in the ovary.

Increased estrogen can cause endometrial hyperplasia, which may progress to cancer.

PCOD alters lipid profiles, increasing LDL and decreasing HDL, contributing to cardiovascular risks.

Increased androgens inhibit the production of sex hormone-binding globulin, leading to insulin resistance and diabetes risk.

PCOD can cause obesity, mood changes, depression, and an increased risk of obstructive sleep apnea.

Acanthosis nigricans, pigmented linear marks, are a sign of insulin resistance seen in PCOD.

Hormonal changes in PCOD include increased androgens, LH, estrogen, insulin, and LDL, with decreased FSH, sex hormone-binding globulin, progesterone, and HDL.

Long-term consequences of PCOD include increased cardiovascular risks, diabetes, endometrial and breast cancers, sleep apnea, and mood disorders.

The Rotterdam criteria (2003) are used for diagnosing PCOD, focusing on symptoms, clinical and biochemical signs, and ultrasound findings.

First-line treatment for PCOD includes weight reduction, lifestyle modifications, and oral contraceptive pills (OCPs) for irregular periods.

For insulin resistance, metformin is prescribed, and for hirsutism, OCPs with ciproteron acetate are used.

In cases of infertility with PCOD, selective estrogen receptor modulators like clomiphene citrate are the first line of treatment.

If medical treatments fail, laparoscopic ovarian drilling may be performed as a surgical option for PCOD.

Transcripts

hello friends let us now learn some

important points about

polycystic ovarian disease or polycystic

ovarian syndrome also called has steen

lavental syndrome

so in this steel levinthal syndrome the

basic pathology in this is increased

androgen production

whatever the reason is here

most commonly there will be increased

androgen production

this increased androgen reduction will

first leads to historism this increased

androgen stimulates the growth of sexual

terminal hair resulting in hirsutism

then

this increased androgen

undergoes peripherally we have aromatase

enzyme

in the presence of this aromatase enzyme

this androgen

gets converted to estrogen

when this androgen gets converted to

estrogen this is trojan has three

effects

one estrogen can decrease follicle

stimulating hormone

once it decreases follicle why does it

decrease follicle stimulating hormone

so increased estrogen is estrogen is

actually produced from ovary ovary

produces estrogen

this production of east ocean by ovary

is activated by follicle stimulating

hormone which is produced by pituitary

so if estrogen is increased in any

regression due to any reason if estrogen

is increased then it exerts negative

feedback mechanism on follicle

stimulating hormone thus there is

decreased follicle stimulating hormone

once there is decreased follicle

stimulating hormone

if you do

a ratio of luteinizing hormone to

follicle stimulating hormone normally it

is one is to do but in patients with

pcod this utilizing heart moon

to follicle stimulating hormone ratio

will be more than two is to one

fine this increased east trojan

will have negative feedback on follicle

stimulating hormone whereas this

estrogen has positive feedback on

luteinizing heart mole and thus

increasing the action of utilizing

hormone

now this luteinizing hormone is

increased

then this luteinizing hormone is

increased first thing is there is no lh

search

normally whenever there is increased lh

surge

that causes an ovulation you can ask me

there is increased neutrinizing hormone

that means there is increased utilizing

that means there is a lh

but this increased

luteinizing hormone is constant

there is constant continuous increase in

luteinizing hormone

but in lh search there will be increase

in

luteinizing hormone

it is strike like suddenly and then it

falls this is a leth search

but here there is continuous increase in

utilizing hormone

this

absence of lh surge

will cause an ovulation ovulation mainly

occurs due to a lh search once there is

no lh search there is no ovulation now

when there is no ovulation this will

decrease the progesterone levels

ovulation will lead to increased

progesterones but because there is no

ovulation there is decreased

progesterone levels overall this will

lead to

in the beginning there will be

oligomenorrhea

but slowly as the days progresses this

disease progresses to secondary

amenorrhoea

right

then

this lh hormone will cause one more

cause we'll have one more issue see

because of this lh increased lh this

increased lh also stimulates

the causes

because lh stimulates the castles this

thicker cells will undergo

hypertrophy and they will produce

androgens again

and this leads to increased androgens

overall

because of thick cell hypertrophy

then

right there is an ovulation very good

if there is an ovulation then what about

the eggs which are to be released

normally every month there will be one

egg which is released one follicle which

is released but if there is an ovulation

there will be formation of multiple

follicles in the ovary and among these

one will grow to a bigger size and it

will form graphene follicle and that is

released outside but in pcod there is no

formation of graphene follicle so there

will be multiple cysts will remain in

the ovary due to this an ovulation

so in pcod you see

the follicles are converted to multiple

cysts in the ovary

right next

then if there is increased androgens now

there is increase so increased estrogens

increased east ocean will act on the

endometrium and it causes endometrial

hyperplasia

as days progresses this endometrial

hyperplasia

will convert into endometrial

hyperplasia with atypia and finally it

can cause

endometrial cancer

and this will also predispose to

breast carcinoma

also

right then

this pcod there is one more important

thing

this pcod also causes alters the lipid

profile

it alters the lipid profile

and it increases the ldl and decreases

hdl and thus it will

lead to cardiovascular risk factors that

is future in future it can cause or it

can lead to heart disease

right now

one important thing is

when there is increased androgens there

is one more important thing

even whenever there is increased

androgens

this increased androgens will inhibit a

hormone

a protein actually this increased

androgens will inhibit a protein called

as serum

sex hormone binding globulin

okay when it inhibits the protein serum

sex hormone binding globulin production

this will result in

increased insulin

this will result in insulin resistance

because of this insulin resistance this

will predispose a patient with

polycystic ovarian disease to diabetes

mellitus

so

so in so this is the main thing that

happens in pcod

right there is one more thing

right because of this increased or

altered lipid profile

this will cause

obesity in the patient

okay because of this excess obesity this

can lead to

mood changes

and depression

and this can also lead to this opacity

can also

cause

sleep apnea especially obstructive sleep

apnea

the increased risk of obstructive sleep

apnea is also seen in these patients

fine

so

if you see the clinical features it's

nothing but whatever is here so the

uh a woman of middle aged women comes to

us with history of menstrual

irregularity that is

primarily irregular cycles and

amenorrhea

and on you can observe that the patient

is obese and there is history of

hirsutism that is acne

alopecia is seen

and you will see that on lipid profile

examination you see there is altered

lipid profile and there is insulin

resistance

so

that is the clinical picture there is

one important thing that occurs in pcod

which is called as a kantosis nigricans

a kantosis nigricans is pigmented linear

marks

which you see in the neck and axilla are

seen in acanthosis nigricans these

acanthosis nigricans occur due to

insulin resistance

insulin resistance leads to this

acanthosis nigricles

right

then

what are the hormonal changes that you

see in pcod

see

in pcod there will be

in pcod there will be increased

androgens number one

that is there will be increased

testosterone increased androstene ion

and increased dihydroxy ep androsterone

then there will be increased luteinizing

hormone

there is increased estrogen

and because of this insulin resistance

the insulin will not dixie because of

this insulin resistance insulin will not

act on peripheral tissues

so there will be increased insulin which

is present in our body because it is not

going to act on the peripheral tissues

so there will be increased insulin and

there will be increased

ldl

low density lipoproteins so water

increased in pcod there will be

increased androgens increased estrogens

increased luteinizing hormone and

increased

insulin and increased

low density lipoprotein is seen in

utilizing hormone that water decreased

in

polycystic ovarian disease in polycystic

ovarian disease there will be decreased

follicle stimulating hormone

there will be androgens will inhibit

sex hormone binding globulin so sex

hormone binding globulin is decreased

and there will be

decreased progesterone

okay

and there will be decreased hdl

so in polycystic ovarian disease you see

there is decreased sex hormone binding

globulin decreased follicle stimulating

hormone decreased hdl and decreased

progesterone

then

if you are asked about the long term

consequences of this newtonizing

of this follicle sorry polycystic

ovarian disease what are the long term

consequences

due to this polycystic ovarian disease

in the long term because of this altered

lipid profile this will cause increased

cvs risk factors especially coronary

artery disease increases in the patient

on long term because of insulin

resistance there is increased risk of

diabetes mellitus in the future due to

increased estrogen there is increased

risk of endometrial carcinoma and also

breast carcinoma is noted in the future

then

because the patient becomes obese there

is increased risk of sleep apnea

and also there will be more changes and

depression these more changes and

depression are also attributed to

estrogen

estrogen and project decreased

progesterone

also causes more changes and depression

and there is one important long-term

consequence which is not there in this

chat that is non-alcoholic

steatohepatitis

non-alcoholics tiato hepatitis

is also long-term risk factor of

polycystic ovarian disease

right

now what about the diagnostic criteria

so the diagnostic criteria we have a

name for this diagnostic criteria that

is rotterdam criteria this is rather

damn criteria according to this

rotterdam criteria 2003

first there will be symptoms of

oligomenorrhea

or amnoria are seen

then clinically

there the patient will have increased

serum testosterone will be diagnosed or

that is first clinical efficacy the

first we have first

criteria is symptoms that is presence of

oligomenorrhea

or amenorrhea second symptom is clinical

plus biochemical symptom

okay in clinical symptom we have the

patient will have hypsotism

comes under clinical symptom

whereas in biochemical symptom

we have increased serum testosterone

actually this serum testosterone levels

should be between 70 to 150 nanogram per

deciliter

these should not be more than 200

nanogram per deciliter

if the serum testosterone levels are

more than 200 nanogram per deciliter

then we do not consider polycystic

ovarian disease

then what do we consider if there is

serum testosterone levels are more than

200 nanograms per deciliter then we will

consider presence of ovarian tumor

rather than polycystic ovarian disease

so in polycystic ovarian disease serum

testosterone should be between

70 to 150 nanogram per deciliter

then third criteria is radiology that is

in usg you will see presence of two or

more cysts

which are of size 2 to 9

mm so 12 or more cysts which are of size

2 to 9 mm which is present in one or

both ovaries

with ovaries more than 10 ml that is

enlarged ovaries so this numbers are

important in usg you will see 12 or

presents of 12 or more cysts which are

of 2 to 9 mm in diameter present in one

or both the ovaries

and each ovary is enlarged that is more

than 10 ml

volume

so this is the rotterdam criteria which

includes

clinical symptoms then clinical and

biochemical symptoms then

ultrasonography

then

how are you going to treat these

patients with pcod

so if a patient comes to you with

pcod

so if a patient comes to you with pcod

first line treatment is giving selective

estrogen receptor modulator

so in this selective estrogen receptor

modulator

the

we can give

clomiphene citrate

and tamoxifen

and reloxified

fine this is fine but do you give them

for first line no they are actually the

first line for infertility

so this is if the patient suffers from

infertility with pcod then the first

line is

selective estrogen receptor modulators

if the patient suffers from pcod always

ask her for weight reduction

and lifestyle modifications are the

first line

first step you give the patient is

to decrease obesity through weight

reduction lifestyle modifications and

exercises

even after that if there is no

uh you know it does not resolve and if

there are irregular periods

then you should give

ocps

oral contraceptive pills

and if there is insulin resistance or

hyperinsulinism

then you should give

metformin

so treatment mainly depends upon the

symptoms

if there is hyposodism if there is

similar if there is hirasutism then you

should give ocps with clomiphene citrate

so the treatment mainly depends with the

sorry

i'm really sorry you should give oc

piece with

c protein acetate

i'm really sorry ocp is with ciproterron

acetate

bro

i'll write it properly

cipro tear on

acetate

okay for his hisotism you should give

ocps with ciproteuron acetate

okay so pcod first line you will do

weight reduction and lifestyle

modifications followed by you should

give symptomatic treatment for irregular

periods you should give ocps

okay for insulin

should be given

sorry metformin should be given for

insulin resistance so you will treat it

according to the symptoms but if there

is infertility with pcod

in such cases the first line is giving

selective estrogen receptor modulators

then following these selective estrogen

receptor modulators in these the drug of

choice is chlamyfin citrate

okay among these selective estrogen

receptor modulators drug of choice is

chromophil citrate if the person cannot

tolerate chlamyfin citrate then you give

them oxyphen

even if the person

okay this reloxifen is not normally used

it is not generally used then if you see

the second lines second line will be you

can use either gonadotropins

or you can use lh and fsh injections can

also be used

and if you see the third line

in third line we can use leukolyte or

gaucher aline can also be used third

line is mainly gnrh analogs

so for pcod with infertility you can use

selective estrogen receptor modulator

and second line drugs like gonadotropins

and lhfsh injections can be given and

you can also use chronotropine releasing

hormone analogs

but

then

if even after doing everything if still

this does not dissolve then you should

do surgery

and in the surgery for pcos we have

laparoscopic ovarian drilling

where you will pass a monopolar cautery

into the ovary this is the ovary with

polycysts many cysts then you will pass

a monopolar cautery into the

ovary and destroy the ovarian thicker

all the thicker you will destroy it

so this is about the polycystic ovarian

disease thank you guys for watching my

lecture

thank you

you