Polycystic Ovarian Syndrome
Original Editors - Amanda Tieken from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Definition/Description[edit | edit source]
Polycystic Ovarian Syndrome (PCOS), formerly known as Stien-Leventhal Syndrome, is a disorder affecting the hormones of women of childbearing age. Ovaries are enlarged secondary to multiple cyst formations within the ovaries.
PCOS has also been associated with features of metabolic syndrome which include insulin resistance and diabetes mellitus as well as cardiovascular factors such as dyslipidemia. Causative factors seem to be unknown but there are certain predispositions that are strongly correlated with the incidence of PCOS. Insulin resistance and compensatory hyperinsulinemia are said to be significant causes of hyperandrogenism in women with PCOS. Furthermore, obesity worsens these hormonal imbalances thus making the clinical features evident - it has been observed that women with PCOS who are obese have a higher incidence of menstrual irregularities and hirsutism compared to non-obese women with PCOS.
Prevalence[edit | edit source]
Polycystic Ovarian Syndrome PCOS affects 4-12% of childbearing aged women It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age. 
- 50% of these women have amenorrhea
- 30% of these women have abnormal menstrual bleeding
- 60% of these women are obese
- 40% of women with PCOS have associated insulin resistance and type 2 diabetes mellitus
Pathophysiology[edit | edit source]
Polycystic Ovarian Syndrome PCOS is believed to be a genetically inherited metabolic and gynecological disorder. A repetitive vicious cycle occurs with hormones resulting in the progression of PCOS. To begin with, failure of an ovary to release oocyte results in increased levels of androgen production/release from the ovaries as well as the adrenal cortex. Excess androgens have a twofold effect. First, androgens are stored in adipose tissue where they are then converted into estrogen. Excess androgens then result in an increased production of Sex Hormone Binding Globulin (SHGB). This increased SHGB then has the consequence of an even greater fabrication of androgens and estrogens. Thus the cycle begins. The cause of the excess androgen production has been correlated to surplus Luteinizing hormone (LH) stimulation resulting in the presence of cystic changes in the ovaries.
Characteristics/Clinical Presentation[edit | edit source]
Signs and symptoms of PCOS include the following:
- Enlarged polycystic ovaries
- Obesity and central fat distribution
- Hirsutism - male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs 
- Virilization - development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass, and clitoromegaly
- Anovulation - failure of the ovaries to release an oocyte
- Amenorrhea - the absence of a menstrual period in women of childbearing age
- Oligomenorrhea - the presence of menstrual cycles greater than 35 days apart
- Dysfunctional uterine bleeding
- Acne related to hyperandrogenism
- Infertility; recurrent first trimester miscarriages
- Obstructive Sleep Apnea
Associated Co-morbidities[edit | edit source]
- Type 2 Diabetes Mellitus
- Cardiovascular disease
- Ovarian cancer
- Breast cancer
- Endometrial cancer
Diagnosis[edit | edit source]
There is no single specific test that can be used to accurately diagnose Polycystic Ovarian Syndrome. Rather a comprehensive examination needs to be carried out by a clinician which involves a detailed history, physical examination and investigative procedures. Clinicians should focus on taking a detailed menstrual history for any irregularities, any significant change in the patient's weight and physical appearance (acne, alopecia, terminal hair, acanthuses nigricans, skin tags). Investigations that could help arrive at a definite diagnosis include:
- Ultrasound - An ultrasonic test allows visualization of any cysts which may be present on the ovaries or if there is any enlargement of one or both ovaries. A transvaginal ultrasound which involves inserting the probe into the vagina is usually done for women who have been sexually active. For women who are not sexually active, an abdominal ultrasound is opted for where the ovaries are viewed from outside the abdominal wall however, a clearer picture is obtained transvaginally compared to a transabdominal ultrasound.
- Hormonal Blood Tests
- Hyperandrogenism - Testing for androgen levels and free androgen index (FAI) is best for diagnosis hyperandrogenism which is a key finding in women with PCOS.
- Tests to detect female hormonal levels - Estradiol, Follicle Stimulating Hormone, Luteinizing Hormone levels.
- Tests to exclude other conditions which could present as Polycystic Ovarian Syndrome PCOS - Thyroid Stimulating Hormone, Prolactin, Adrenal hormones.
Criteria for Diagnosis[edit | edit source]
A conclusive diagnosis for PCOS can be made if at least 2 out of 3 of the following is found criteria are met:
- Polycystic ovaries - 12 or more follicles are seen on one ovary or the size of one or both ovaries have enlarged.
- Hyperandrogenism - high levels of androgenous hormones or male pattern of hair growth.
- Menstrual Abnormalities - lack of menses or menstrual cycle irregularities or anovulation.
Medical Management[edit | edit source]
Medical management is completed through medications or surgical removal of the ovarian cysts/hysterectomy. Medications can be used to shrink ovarian cysts through control of the menstrual cycle and subsiding release of excess luteinizing hormone thus preventing the overproduction of testosterone.
Medications[edit | edit source]
Treatment for infertility may include the following for inducing ovulation:
- Clomiphene citrate
- Metformin increases spontaneous ovulation for women with insulin resistance/increased insulin production
Treatment for those not interested in conceiving a child may include:
- Depo-Provera injections to decrease endometrial hyperplasia
- Oral progestin
- Oral combination contraceptive containing estrogen and progestin
Cystectomy[edit | edit source]
Physical Therapy Management[edit | edit source]
Exercise training has shown great improvement in 50% of the women diagnosed with Polycystic Ovarian Syndrome PCOS, by targeting menstrual irregularities and promoting ovulation. Weight reduction is an important component of the physical therapy program since weight reduction improves glucose intolerance which in turn could resolve the reproductive and metabolic derangements often associated with PCOS. Weight loss may also reduce the pulse amplitude of luteinizing hormone thus reducing androgen production.
Physical therapists should also be aware of the clinical presentation of Polycystic Ovarian Syndrome PCOS. Women with PCOS may experience low back pain, sacral pain, and lower quadrant abdominal pain. However, a thorough patient history can provide information about a gynecologic/metabolic connection. The concern of the possible presence of Polycystic Ovarian Syndrome PCOS requires immediate referral to a physician.
In treating patients with a past medical history of Polycystic Ovarian Syndrome PCOS for a non-related condition, be aware of related medical concerns that may affect the patient's ability to participate in activities including glucose intolerance and insulin resistance.
Side effects of medications need to also be taken into account. For example, the side effects of clomiphene citrate, an ovulation inducer, include insomnia, nausea/vomiting, blurry vision, and frequent urination.
Lifestyle Changes[edit | edit source]
- Weight loss - Cornerstone in controlling all derangements seen in PCOS
- Regular exercise (30min/day) lowering insulin levels - walking/jogging
- Dietary Modifications - Reduction of carbohydrates consumed to reduce insulin levels
Differential Diagnosis[edit | edit source]
- Late-onset Congenital Adrenal Hyperplasia
- Ovarian Tumor
- Adrenal tumor
- Cushing's Syndrome 
Resources[edit | edit source]
References[edit | edit source]
- Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based review. Saudi Journal of Sports Medicine. 2017 Sep 1;17(3):123.
- Sheehan MT. Polycystic ovarian syndrome: diagnosis & management. Clinical Medicine & Research 2004;2:13-27.
- Harrison CL, Lombard CB, Moran LJ, Teede HJ. Exercise therapy in polycystic ovary syndrome: a systematic review. Human Reproduction Update. 2010 Sep 10;17(2):171-83.
- Goodman CC, Fuller KS, editors. Pathology: implications for the physical therapist. 3rd ed. St Louis: Saunders Elsevier, 2009.
- Daniilidis A, Dina K. Long term health consequesnces of polycystic ovarian syndrome: a review analysis. Hippokratia 2009; 13:90-92.
- Callahan TL, Caughey AB, editors. Blueprints: obstetrics & gynecology. 5th ed. Baltimore: Lippincott Williams & Wilkins, 2009.
- Futterweit W, Diamanti-Kandarakis E, Azziz R. Clinical features of the polycystic ovary syndrome. InAndrogen Excess Disorders in Women 2006 (pp. 155-167). Humana Press.
- Merck manual of medical information. 2nd ed. New York: Merck & Co., Inc, 2003. p 1234-35.
- Williams T, Mortada R, Porter S. Diagnosis and Treatment of Polycystic Ovary Syndrome. American family physician. 2016 Jul 15;94(2).
- Jean Hailes: How is PCOS diagnosed? Available from: https://jeanhailes.org.au/health-a-z/pcos/how-is-pcos-diagnosed [Accessed 30th June 2018]