What is Polycystic Ovarian Syndrome?
Polycystic
Ovarian Syndrome (PCOS, or Stein-Leventhal Syndrome) is a
disorder characterized by anovulation, hirsutism and obesity.
There is an increased sensitivity of the ovaries to gonadotropins,
an increase in androgen levels and a propensity to develop
ovarian microcysts.
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DIAGNOSIS
OF PCOD
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- Disordered
or absent menstrual cycles and failure of ovulation
- High
levels of plasma androstenedione and testosterone
or free testosterone
- High
plasma LH:FHS ratios or >3:1
- Higher
levels of bioactive LH
- Masculinization
of facial and pubic hair and body characteristics
- Obesity
in some patients
- Many
small follicles on ultrasound or in ovarian biopsies
- Obese
and hirute patients may have exaggerated insulin
responses in oral glucose tolerance test
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Various
therapies are available for hyperandrogenic syndromes. Ovarian
wedge resection is the classic method for treating PCOD.
It is surprisingly effective and even enjoying a resurgence
today. The reduction in ovarian mass can have dramatic effects,
with a decrement in ovarian androgen secretion interrupting
the vicious cycle that results in exaggerated LH and reduced
FSH release. Later laparoscopic wedge resection involves
creating multiple pockets 1 cm deep throughout the surface
of the ovary, to destroy a significant amount of ovarian
cortex and stroma. All surgical methods are contraindicated
in patients desiring pregnancy, because of the risks of
producing potentially severe periovarian adhesions.
Medical methods involving dexamethasone or other compounds,
and especially LH-RHa are effective with many forms of the
syndrome. Dexamethasone will suppress the adrenal glands
and reduce the output of estradiol but not of progesterone
by granulosa cells.
LH-RHa effectively suppresses ovarian perandrogenism. Androgen
levels decline rapidly to those typical women after oophonectomy.
Gonadotrophs are desensitized and LH and estradiol levels
decline for up to 550 days. Care is essential in inducing
ovulation in PCOD patients. When used to induce ovulation,
LH-RHa can induce explosive responses in PCOD patients with
elevated LH and normal FSH and increase LH pulse frequency
without a nocturnal slowdown. Their LH:FSH ratios increase
enormously as pituitary sensitivity to LH-RH is enhanced.
PCOD patients may be given LH-RHa before FSH or hMG for
ovarian stimulation. Responses are better than with FSH
or hMG alone. Many follicles can develop posing the threat
of ovarian hyperstimulation syndrome. Clomiphene triggers
follicle growth in some patients but others will have clomiphene
resistance.
Principles & Practice of Assisted Human Reproduction
Robert G Edwards, PhD & Steven A Brody M.D.
W.B. Sanders
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