Foods you can eat with Polycystic Ovarian Syndrome

The Natural Pcos Diet

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Polycystic Ovarian Syndrome

PCOS is a common disorder of premenstrual women characterized by hyperandrogenism, chronic anovulation, menstrual irregularity, hyperinsulin-emia, and often (for which it is a major cause) infertility (106,107). Prevalence estimates range from 5 to 10 of menstruating females. It was first reported in 1980 that women with PCOS had hyperinsulinemia, suggesting the presence of insulin resistance (108-110). Subsequently, many women with PCOS were found to have subtle acanthosis nigricans, a skin darkening often associated with insulin resistance. Women with chronic anovulation and hyperandrogenemia (111,112) without secondary causes were found to have glucose intolerance and elevated insulin levels (55). That PCOS is associated with insulin resistance and hyperglycemia following an oral glucose tolerance test (OGTT) was first demonstrated by Dunaif in 1987 (109). Forty percent of PCOS patients who are also obese have IGT or frank type 2 diabetes, and this remains consistent despite ethnic...

Polycystic Ovary Syndrome Diabetes and Cardivascular Disease

PCOS is the most common endocrinopathy that affects women of reproductive age (177). Data on the exact prevalence are variable mostly because of the lack of well-accepted diagnostic criteria. At present, the diagnosis of PCOS is based on the presence of ovulatory dysfunction and clinical or biochemical evidence of hyperandrogenism. The diagnosis requires a complete evaluation for exclusion of other causes of hyperandrogenism such as nonclassic adrenal 21-hydroxylase deficiency and androgen secreting neoplasms. The presence of polycystic ovaries on ultrasound is not a criterion for diagnosis as this is commonly found in randomly selected women (178). Although PCOS is known to be associated with reproductive morbidity and increased risk for endometrial cancer, diagnosis is especially important because PCOS is now thought to increase metabolic and cardiovascular risks (179). These risks are strongly linked to insulin resistance which is present in both obese and lean women with PCOS.

Polycystic Ovary Syndrome and Cardiovascular Risk

PCOS is associated with an increase in cardiovascular risk factors (189). In addition to obesity that is commonly present and independently associated with increased cardiovascular risk, women with PCOS have dyslipedemia, hypertension and elevated PAI-1 levels. Obesity is a prominent feature in women with PCOS as about half of the patients are obese. Also, obesity appears to confer an additive and synergistic effect on the mani Women with PCOS have higher serum triglycerides, total and LDL cholesterol and lower HDL cholesterol levels than weight-matched regularly menstruating women (190). These findings however, vary and depend on the weight, diet and ethnic background. In a large study of non-Hispanic white women, elevated LDL-C was the predominant lipid abnormality in women with PCOS (191). An additional parameter contributing to the elevated cardiovascular risk is hypertension. Obese women with PCOS have an increased incidence of hypertension and sustained hypertension is threefold...

Effect of Insulin Resistance Treatment on Polycystic Ovary Syndrome Weight Loss

Weight reduction is of paramount importance and cornerstone of every therapeutic strategy in PCOS. Although obesity does not seem to be the primary insult in PCOS, many studies have demonstrated the beneficial impact of weight reduction on the manifestations of the syndrome and especially insulin sensitivity, risk for diabetes and adverse cardiovascular risk profile (199). The effect of weight reduction by a hypocaloric low-fat diet on the metabolic and endocrine variables was studied in obese women with PCOS In another study, the effect of dietary intervention on insulin sensitivity and lipids, fibrinolysis and coagulation was examined also in obese women with PCOS (201). Insulin sensitivity was assessed by the eyglycemic clamp technique before and after a very low-calorie, protein-rich diet for 4 weeks that was followed by a low-calorie, low-fat diet for 20 weeks. After the 24-week intervention, insulin sensitivity was significantly increased along with a significant reduction of...

Introduction defining polycystic ovary syndrome and secondary amenorrhoea

In this chapter we shall first describe in detail our current understanding of polycystic ovary syndrome (PCOS), which is a condition that presents with ovarian dysfunction and endocrine problems and is also associated with hyperinsulinaemia and metabolic disease. The polycys-tic ovary syndrome is a heterogeneous condition which is defined by the presence of two out of the following three criteria 1 oligo- and or anovulation 2 , hyper-androgenism (clinical and or biochemical) 3 , polycystic ovaries, with the exclusion of other aetiologies. PCOS therefore encompasses symptoms of menstrual cycle disturbance and as such is the commonest cause of secondary amenorrhoea. The second part of the chapter will discuss the pathophysiology and management of other causes of secondary amenorrhoea.

Polycystic ovary syndrome

The polycystic ovary syndrome (PCOS) is a heterogeneous collection of signs and symptoms that gathered together form a spectrum of a disorder with a mild presentation in some, while in others a severe disturbance of reproductive, endocrine and metabolic function. The pathophysiology of the PCOS appears to be multifacto-rial and polygenic. The definition of the syndrome has been much debated. Key features include menstrual cycle disturbance, hyperandrogenism and obesity. There are many extra-ovarian aspects to the pathophysiology of PCOS, yet ovarian dysfunction is central. At a recent joint ESHRE ASRM (European Society for Human Reproduction and Embryology American Society for Reproductive Medicine) consensus meeting a refined definition of the PCOS was agreed namely the presence of two out of the following three criteria 2 Hyperandrogenism (clinical and or biochemical) 3 Polycystic ovaries (The Rotterdam ESHRE ASRM-sponsored PCOS consensus workshop group, 2004). Other aetiologies of...

The pathophysiology of PCOS

Manifestation of the syndrome, hyperandrogenism, but is also one of the mechanisms whereby follicular growth is inhibited with the resultant excess of immature follicles. Hypersecretion of luteinizing hormone (LH) by the pituitary - a result both of disordered ovarian-pituitary feedback and exaggerated pulses of GnRH from the hypothalamus - stimulates testosterone secretion by the ovary. Furthermore, insulin is a potent stimulus for androgen secretion by the ovary which, by way of a different receptor for insulin, does not exhibit insulin resistance. Insulin therefore amplifies the effect of LH, and additionally magnifies the degree of hyperandrogenism by suppressing liver production of the main carrier protein sex hormone binding globulin (SHBG), thus elevating the 'free androgen index'. It is a combination of genetic abnormalities combined with environmental factors, such as nutrition and body weight, which then affect expression of the syndrome.

Racial differences in expression of PCOS

The highest reported prevalence of PCO has been 52 among South Asian immigrants in Britain, of whom 49.1 had menstrual irregularity 13 . Rodin et al. 13 demonstrated that South Asian women with PCO, had a comparable degree of insulin resistance to controls with established type 2 diabetes mellitus. Insulin resistance and hyperinsulinaemia are common antecedents of type 2 diabetes, with a high prevalence in South Asians. Type 2 diabetes also has a familial basis, inherited as a complex genetic trait that interacts with environmental factors, chiefly nutrition, commencing from fetal life. South Asians with anovulatory PCOS have greater insulin resistance and more severe symptoms of the syndrome than anovu-latory white Caucasians with PCOS 14 . Furthermore, women from South Asia, living in the UK appear to express symptoms at an earlier age than their Caucasian British counterparts.

Heterogeneity of PCOS

The findings of a large series of more than 1700 women with polycystic ovaries detected by ultrasound scan, are summarized in Table 39.4 1 . All patients had at least one symptom of the PCOs. Thirty-eight percent of the women were overweight (BMI > 25 kg m2). Obesity was significantly associated with an increased risk of hirsuit-ism, menstrual cycle disturbance and an elevated serum testosterone concentration. Obesity was also associated with an increased rate of infertility and menstrual cycle disturbance. Twenty-six percent of patients with primary infertility and 14 of patients with secondary infertility had a BMI of more than 30 kg m2. Table 39.3 Signs and symptoms of polycystic ovary syndrome Hyperandrogenism (acne, hirsutism, alopecia - not virilization) Menstrual disturbance Infertility Obesity Sometimes asymptomatic, with polycystic ovaries on ultrasound scan Table 39.4 Characteristics of 1741 women with ultrasound-detected polycystic ovaries Table 39.4 Characteristics of...

Polycystic Ovarian Syndrome and Insulin Resistance

The association between insulin resistance and PCOS has been well recognized for almost two decades. Insulin resistance refers to an impairment of insulin-stimulated glucose uptake largely in skeletal muscle and an impairment in insulin-mediated inhibition of hepatic glucose output. In skeletal muscle and fat, insulin initiates several intracellular signals culminating in GLUT 4-mediated glucose uptake. Insulin also has a vasodilator effect on the normal skeletal muscle vasculature mediated by stimulation of endothelium-derived nitric oxide (NO). In endothelial cells in vitro, insulin-stimulated NO production shares signaling pathways similar to those mediating glucose uptake in muscle and fat (15-17). The presence of insulin resistance leads to increased p-cell insulin secretion with compensatory hyperinsulinemia. Type 2 diabetes mellitus (DM) develops when insulin resistance is accompanied by p-cell dysfunction (15). Although a controlled randomized study has not been performed to...

Management of the polycystic ovary syndrome

Overstimulated Ovaries

The clinical management of a woman with PCOS should be focused on her individual problems. Obesity worsens both symptomatology and the endocrine profile and so obese women (BMI > 30 kg m2) should therefore be encouraged to lose weight. Weight loss improves the endocrine profile, the likelihood of ovulation and a healthy pregnancy. Much has been written about diet and PCOS. The right diet for an individual is one that is practical, sustainable and compatible with her lifestyle. It is sensible to keep carbohydrate content down and to avoid fatty foods. It is often helpful to refer to a dietician. Anti-obesity drugs may help with weight loss. Metformin has not been shown to be valuable to aiding weight reduction. Amenorrhoeic women with PCOS are not oestrogen deficient and are not at risk of osteoporosis. Indeed they are oestrogen replete and at risk of endometrial hyperpla-sia (see p. 385). The easiest way to control the menstrual HYPERANDROGENISM AND HIRSUTISM The bioavailability of...

Examination and investigation of patients with PCOS and secondary amenorrhoea

Signs of hyperandrogenism (acne, hirsutism, balding (alopecia)) are suggestive of the PCOS, although biochemical screening helps to differentiate other causes of androgen excess. It is important to distinguish between hyperandrogenism and virilization, which is additionally associated with high circulating androgen levels and causes deepening of the voice, breast atrophy, increase in muscle bulk and cliteromegaly (see Virilization p. 378). A rapid onset of hirsutism suggests the presence of an androgen secreting tumour of the ovary or adrenal gland. Hirsutism can be graded and given a 'Ferriman-Gallwey Score', by assessing the amount of hair in different parts of the body (e.g. upper lip, chin, breasts, abdomen, arms and legs). It is useful to monitor the progress of hirsutism, or its response to treatment, by making serial records, either using a chart or by taking photographs of affected areas of the body. One should be aware of the possibility of Cushing's syndrome in women with...

PCOS in younger women

The majority of studies which have identified the risk factors of obesity and insulin resistance in women with PCOS have investigated adult populations, commonly including women who have presented to specialist endocrine or reproductive clinics. However, PCOS has been identified in much younger populations 9 , in which women with increasing symptoms of PCOS, however, were found to be more insulin resistant. These data emphasize the need for long-term prospective studies of young women with PCOS to clarify the natural history, and to determine which women will be at risk of diabetes and cardiovascular disease later in life. A study of women with PCOS and a mean age of 39 years followed over a period of 6 years, found that 9 of those with normal glucose tolerance developed impaired glucose tolerance (IGT) and 8 developed NIDDM 17 . While 54 of women with IGT at the start of the study had NIDDM at follow-up. The risks of disease progression, not surprisingly, were greatest in those who...

Health consequences of polycystic ovary syndrome

Obesity and metabolic abnormalities are recognized risk factors for the development of ischaemic heart disease (IHD) in the general population, and these are also recognized features of PCOS. The question is whether women with PCOS are at an increased risk of IHD, and whether this will occur at an earlier age than women with normal ovaries. The basis for the idea that women with PCOS are at greater risk for cardiovascular disease is that these women are more insulin resistant than weight-matched controls and that the metabolic disturbances associated with insulin resistance are known to increase cardiovascular risk in other populations. Insulin resistance is defined as a diminution in the biological responses to a given level of insulin. In the presence of an adequate pancreatic reserve, normal circulating glucose levels are maintained at higher serum insulin concentrations. In the general population cardiovascular risk factors include insulin resistance, obesity, glucose intolerance,...

Genetics of PCOS

The PCOS has long been noted to have a familial component 11 . Genetic analysis has been hampered by the lack of a universal definition for PCOS. Most of the criteria used for diagnosing PCOS are continuous traits, such as, degree of hirsutism, level of circulating andro-gens, extent of menstrual irregularity, and ovarian volume and morphology. To perform genetic analyses these continuous variables have to be transformed into nominal variables. Family studies have revealed that about 50 of first-degree relatives have PCOS suggesting a dominant mode of inheritance 12 . Commonly first-degree male relatives appear more likely to have premature baldness and metabolic syndrome. As hyperandrogenism is a key feature of PCOS it is logical to explore the critical steps in steroidogenesis and potential enzyme dysfunction. Some studies have found an abnormality with the cholesterol side chain cleavage gene (CYP11a), which is the rate limiting step in steroidogenesis. It has been hypothesized...

Etiologic Classification

Roidism, hypogonadism, polycystic ovarian syndrome hypothalamic lesions secondary to trauma, surgery, or primary or metastatic tumor genetic syndromes like leptin deficiency, leptin receptor melanocortin receptor defects, Prader-Willi, Bardet-Biedl, and Down's and drugs such as insulin, sulfonylureas, glucocorticoids, antiepileptics, antipsychotics, and depoprovera.

Diabetes and fibrinolysis

Decreased fibrinolytic system capacity is observed consistently in blood from patients with DM, particularly those with type 2 diabetes (93,94). It has been known for many years that obesity is associated with impaired fibrinolysis (95) that elevated blood triglycerides and other hallmarks of hyperinsulinemia are associated with increased activity of PAI-1 (96) and that elevated PAI-1 is a marker of increased risk of acute MI as judged from its presence in survivors compared with age-matched subjects who had not experienced any manifestations of overt CAD (97). We found that impaired fibrinolysis in subjects with type 2 DM, not only under baseline conditions but also in response to physiological challenge, was attributable to augmented concentrations in blood of circulating PAI-1. Furthermore, obese diabetic subjects exhibited threefold elevations of PAI-1 in blood compared with values in nondiabetic subjects despite tissue-type plasminogen activator (t-PA) values that were virtually...

Mechanisms responsible for the overexpression of pai1 in diabetes

Therapy designed to reduce insulin resistance, the resultant hyperinsulinemia, or both have been shown to reduce PAI-1 in blood as well. Thus, treatment of women with the polycystic ovarian syndrome with metformin or troglitazone decreased concentrations in blood of insulin and of PAI-1 (100,103). Changes in the concentrations of PAI-1 in blood correlated significantly with those of insulin (100). The concordance supports the view that insulin contributes to the increased PAI-1 expression seen in vivo. indicative of syndromes of insulin resistance such as high body mass index and waist to hip ratio in addition to advanced age and elevated concentrations of triglycerides, the association of PAI-1 activity with physical activity was no longer significant. This observation, particularly in combination with the results seen after therapy with troglitazone and metformin in women with the polycystic ovarian syndrome, demonstrates that interventions designed to attenuate insulin resistance...

Sources of Estrogens in Women

In the circulation, estrogen binds to sex hormone binding globulin (SHBG) produced in the liver and, with less affinity, to albumin (11). Only about 2 -3 of estrogen is free. Changes in SHBG levels may influence the tissue availability of free estrogen and also free androgen because the latter also binds to SHBG. Estrogens themselves increase, whereas androgens and high insulin levels decrease SHBG levels. During the menopause, the drop of estradiol reduces SHBG levels, which in turn, results in decreased binding and an increased concentration of free androgens. Consequently, estrogens decrease to a greater extent than do androgens resulting in an increase of the androgen estrogen ratio and a relative androgen excess in postmenopausal women. Some of the signs and symptoms observed after menopause and, in particular, changes in body composition are caused by this altered balance between estrogens and androgens (12).

Anuja Dokras md phd and William I Sivitz md

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. The clinical presentation commonly includes infertility, irregular menses, obesity, and hirsutism, and hence women may initially present to the gynecologist or reproductive endocrinologist. However, women with PCOS are also at an increased risk for a number of medical problems including diabetes, hypertension, coronary artery disease, and endometrial cancer and may first present to an internist, medical endocrinologist, gynecologic oncologist, or cardiologist. Thus, PCOS is a multifaceted endocrine and metabolic disorder, which needs early recognition and treatment to prevent long-term complications. In this chapter we present current views on diagnosis and therapy. PCOS affects 5-10 of premenopausal women (1). It is characterized by chronic anovulation and hyperandrogenism soon after puberty. Drs. Stein and Leventhal first described PCOS in 1935 in seven women with amenorrhea,...

Women Not Interested in Fertility

The lack of menstrual regularity predisposes women with PCOS to a threefold risk of endometrial cancer (46). Data from the Cancer and Steroid Hormone study found a fivefold increased risk of endometrial cancer in women with PCOS Odds ratio (OR) 5.4 95 confidence interval (CI) 2.4-12.3 (47). This increased risk is attributed to prolonged periods of unopposed estrogens, resulting in mito-genic stimulation of the endometrium. Peripheral aromatization into estrone and low circulating SHBG levels, resulting in increased free estradiol concentrations, further contributes to the chronic estrogen action on the endometrium. Fortunately, most cases of endometrial cancer are detected at an early stage with well-differentiated histology and good prognosis (48). Nonetheless, women with PCOS who are not interested in fertility should be treated with oral contraceptive pills (OCPs) or a 14-d course of cyclic progestin each month to induce regular withdrawal bleed and prevent endometrial hyperplasia...

Bromocriptine Parlodel

Parlodel is a medication that slows or stops the production of the hormone prolactin in the brain's pituitary gland. It is very useful in treating women with abnormally high prolactin levels. Very high levels of prolactin may be due to polycystic ovary syndrome (PCOS), hormonal imbalance, or a benign tumor in the pituitary gland called a pituitary adenoma. Unfortunately, high prolactin levels interfere with the body's normal production of LH and FSH and thus hinder the ovulation process. Parlodel is prescribed to lower the prolactin level and therefore allow ovulation to occur.

Neurological Abnormalities

Generally, women with voiding dysfunction in the absence of structural abnormalities of the lower urinary tract are very difficult to manage. A small group of female patients with obstructed voiding, and in some cases AUR, have been shown to have a specific electro-myographic abnormality of the striated urethral sphincter, explaining their symptoms. When associated with features of polycystic ovary syndrome (PCOS), these patients are said to have Fowler's syndrome (Ka-via et al. 2006 Fowler and Kirby 1984,1985). They characteristically present at age 20-30, with episodes of AUR, and are often intolerant of urethral catheteriza-tion. Acutely, they can be managed with urethral cathe-terization, if tolerated, or CISC, although this is often tolerated even less well. Some patients will require su-prapubic bladder drainage for this reason.

Relationship to Insulin Resistance and Diabetes

Although the exact mechanisms that lead to the development of PCOS are not clear it has been shown that insulin resistance and compensatory hyperinsulinemia possess the central role in the pathophysiology of the syndrome. Women with PCOS have both basal and glucose-stimulated hyperinsulinemia compared with weight-matched women and the high levels of insulin are thought to mediate the development of hyperandrogenemia, anovulation, and infertility. At the same time, insulin resistance and compensatory hyperinsulinemia are responsible for the cardiovascular risk factors. The hyperinsulin-ism correlates with the hyperandrogenism and occurs independent of obesity (180,181). The insulin resistance in at least 50 of PCOS women appears to be related to excessive serine phosphorylation of the insulin receptor (182). This abnormality is caused by a factor extrinsic to the insulin receptor, which is presumably a serine threonine kinase. Serine phosphorylation appears to modulate the activity of...

Normal secondary sexual characteristics

The presence of normal secondary sexual characteristics should alert the clinician to the concept that outflow tract obstruction may be occurring. This is the most common cause of primary amenorrhoea in the presence of normal secondary sexual characteristics. It is thus appropriate to carry out investigations to make this diagnosis. It is inappropriate to perform any physical pelvic examination on these young adolescents and imaging techniques should be used. It is simple to arrange for a pelvic ultrasound to assess the pelvic anatomy, and only in rare circumstances where this cannot be delineated by ultrasound should it be necessary to use magnetic resonance imaging (MRI) or computed tomography (CT) scanning. If the uterus is absent the karyotype should be performed and if this is 46XX then the Rokitansky syndrome is the most likely diagnosis. If the chromosome complement is 46XY the patient is, by definition, an XY female. If the uterus is present on ultrasound then there may be an...

Endocrine investigations Table 391

A more permanent, but still moderate elevation (greater than 700 mIU 1) is associated with hypothyroidism and is also a common finding in women with PCOS, where prolactin levels up to 2500 mlU l have been reported 1 . PCOS may also result in amenorrhoea, which can therefore create diagnostic difficulties, and hence appropriate management, for those women with hyperprolactinaemia and polycystic ovaries. Amenorrhoea in women with PCOS is secondary to acyclical ovarian activity and continuous oestrogen production. A positive response to a progestogen challenge test (e.g. medroxyprogesterone acetate 10 mg daily for 5 days), which induces a withdrawal bleed will distinguish patients with PCOS related hyperprolactinaemia from those with polycystic ovaries and unrelated hyperprolacti-naemia, because the latter causes oestrogen deficiency and therefore failure to respond to the progestogen challenge. alone (and is not attributable to the preovulatory LH...

Defining the polycystic ovary Fig 393

Polycystic ovaries are commonly detected by ultrasound or other forms of pelvic imaging, with estimates of the prevalence in the general population being in the order of 20-33 8,9 . Although the ultrasound criteria for the diagnosis of polycystic ovaries have not, until now, been universally agreed, the characteristic features are accepted as being an increase in the number of follicles and the amount of stroma as compared with normal ovaries, resulting in an increase in ovarian volume. The 'cysts' are not cysts in the sense that they do contain oocytes and indeed are follicles whose development has been arrested. The actual number of cysts may be of less relevance than the volume of ovarian stroma or of the ovary itself, which has been shown to closely correlate with serum testosterone concentrations 10 . At the recent ESHRE ASRM consensus meeting a refined definition of the PCOS was agreed, encompassing a description of the morphology of the polycystic ovary. According to the...

Important coexistent pathologies

POLYCYSTIC OVARIES Polycystic ovaries as seen by ultrasound are an extremely common finding in women of child bearing age and can occur in 20 of patients. Patients with polycystic ovaries can be more difficult to stimulate with gonadotrophins either for IUI or IVF. Initially there can be a degree of resistance at lower doses but then a very narrow therapeutic window before the patient overstimulates and this can quite often lead to cycle cancellation. In view of the severe complications resulting from ovarian hyperstimulation syndrome (OHSS), one should always start on a low dose and then build it up in small increments until the appropriate therapeutic window is achieved. Some have advocated the use of laparoscopic ovarian drilling to try and improve this therapeutic window, as well as the pre-cycle treatment of all insulin sensitizing agents such as Metformin. The use of both of these modalities is yet to be fully assessed in prospective randomized controlled studies with IVF...

Further investigations of female infertility

Male Groin Hernia Examination

Miscarriage, termination of pregnancy, ectopic pregnancy Chronic illnesses (diabetes, hypertension, renal disease) Known endocrine disorders, e.g. hypothyroidism, PCOS Previous STD's, e.g. Chlamydia Known endometriosis Galactorrhoea Cervical smear history Current medication including folate from day 21 and continued weekly until the next period begins. Where periods are either very irregular or absent it may be impractical (and irrelevant) to estimate progesterone levels. Instead, additional biochemical investigations are indicated to establish a possible endocrine cause of oligo anovulation (Fig. 45.2). These include early follicular phase FSH and LH, prolactin, TSH, and where PCOS is suspected, serum testosterone androstenedione and SHBG. Where an adrenal cause is to be excluded, DHEA and DHEAS, 17-OH progesterone need to be checked. FSH and LH levels should be checked in the early fol-licular phase (days 1-3) in order to avoid the normal midcycle surge which can lead to abnormally...

Management of secondary amenorrhoea

Asherman's syndrome Cervical stenosis Polycystic ovary syndrome Premature ovarian failure (genetic, autoimmune, infective, radio chemotherapy) Weight loss Exercise Chronic illness Psychological distress Idiopathic Polycystic ovary syndrome OVARIAN CAUSES OF SECONDARY AMENORRHOEA Polycystic ovary syndrome See earlier sections.

Weightrelated amenorrhoea

An artificial cycle, may be induced with the COC. However, this may corroborate in the denial of weight loss being the underlying problem. Similarly, while it is possible to induce ovulation with GnRH, or exogenous gonadotropins, treatment of infertility in the significantly underweight patient is associated with a significant increase in intrauterine growth retardation and neonatal problems. Furthermore, since three quarters of the cell divisions that occur during pregnancy do so during the first trimester, it is essential that nutritional status is optimized before conception. Low birthweight is also now being related to an increased risk of cardiovascular disease, diabetes PCOS in adult life 50 .

Karyotype and other tests

Woman Who Have Lost 100lbs With Pcos

Amenorrhoea may also have long-term metabolic and physical consequences. In women with PCOS and prolonged amenorrhoea, there is a risk of endometrial hyperplasia and adenocarcinoma. If, on resumption of Serum cholesterol measurements are important because of the association of an increased risk of heart disease in women with premature ovarian failure. Women with PCOS 3 , although not oestrogen deficient, may have a subnormal HDL total cholesterol ratio. This is a consequence of the hypersecretion of insulin that occurs in many women with PCOS, and may increase the lifetime risk of heart disease.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHHS) can occur in any IVF cycle, but usually is only mild to moderate. Severe OHHS can be life threatening and should happen in less than 2 of cases. It generally occurs in specific at-risk groups, in particular in young patients who have polycystic ovaries. In these situations the starting dose of gonadotrophins should be lowered to take account of the increased sensitivity of the polycystic ovaries. Even in the best centres with the adequate monitoring there can be a surprisingly brisk ovarian response and the ovaries can hyperstimulate. In these situations several options are available. The cycle can be abandoned and then re-started at a lower dose or the eggs collected, fertilized and then all the embryos electively frozen as severe hyperstimulation tends to be most severe in patients who become pregnant from a fresh transfer. Lastly, if the risks have been fully considered and thought still acceptable, then

Women Interested in Fertility

Most women with PCOS ovulate intermittently and can present with infertility. However, only a subset have infertility secondary to anovulation, and most respond to ovulation-inducing agents. The current medical treatment strategy for PCOS patients to regulate menstruation and treat infertility includes use of an estrogen receptor agonist antagonist such as clomiphene citrate. Clomiphene is typically administered in the follicular phase of the cycle, starting on d 3-5 for a total of 5 d. The starting dose is 50 mg d, and this may be increased in an incremental manner until ovulation is detected, usually by measuring the midluteal progesterone level. Women are asked to time intercourse every other day for 1 wk starting 5 d after the last dose of clomiphene or to use an ovulation prediction kit. This ovulatory dose is then maintained for three to six cycles. It has been reported that 70 of women will ovulate at the 100-mg dose (63). Furthermore, most clomiphene-initiated conceptions will...

Diagnostic categories in infertility

Table 45.4 PCOS - the revised 2003 diagnostic criteria Diagnosis of PCOS includes the presence of two out of the three listed below 2. Clinical and or biochemical signs of hyperandrogenism* 3. Polycystic ovaries * Clinical indicators of hyperandrogenism are hirsutism, acne and androgenic alopecia. The elevation of free testosterone and or free testosterone (free androgen) index (FAI) are the biochemical indicators of PCOS. Some women with PCOS may have isolated elevations in dehydroepiandrosteronesulphate (DHEAS). The definition of polycystic appearing ovaries on scan includes the presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter, and increased ovarian volume (> 10 ml). The ovarian volume is calculated using the formula (0.5 x length x width x thickness). The distribution of follicles is not included in the definition and only one ovary fitting the description is sufficient for the diagnosis. Adapted from The Rotterdam ESHRE ASRM-sponsored PCOS Consensus...

Pathophysiology

Are converted to their 5a metabolites (8). Hence, the follicles are unable to change their microenvironment from androgen dominance to estrogen dominance. Although new follicular growth is continuously stimulated in the ovary in response to normal follicle-stimulating hormone (FSH) concentrations, the follicles fail to achieve complete maturation, contributing to the polycystic appearance. The increased estrogen levels in women with PCOS can be explained on the basis of peripheral conversion of androstenedione to estrone. The underlying mechanisms that lead to the dysregulation of relationships among the hypothalamus, pituitary, and the ovary (resulting in elevated intrac-ellular and peripheral androgens) still need investigation. Recently hyper-insulinemia and insulin resistance have been implicated as pivotal in the pathogenesis of PCOS through a number of mechanisms (Fig. 2), including direct action on the theca cells increasing the amplitude of LH secreted by the pituitary...

Mechanisms

Apart from the above considerations, diabetes may also affect the vascular system in women indirectly, through menstrual cycle irregularities and hypoestrogenemia. Indeed, previous epidemiological studies demonstrated that diabetic premenopausal women more frequently have menstrual irregularities, lower blood estrogen levels and higher androgen levels than nondiabetic women (118). The reasons for these menstrual abnormalities and hypoestrogenemia in women with diabetes are not well known but may be hypotha-lamic in origin related to stress or poor metabolic control or may be related to insulin resistance and hyperinsulinemia (119). Furthermore, in women with type 2 diabetes, low SHBG levels have been reported and this may contribute to relative hyperadrogenemia in these women, a condition frequently seen in women with polycystic ovary syndrome (PCOS) (120). Low SHBG levels are believed to be a marker for future CVD in women (121). Whatever the reason, the diabetes related-menstrual...

Glucose tolerance

Women who are obese, and also many slim women with PCOS, will have insulin resistance and elevated serum concentrations of insulin (usually < 30 mU l fasting). A 75 g oral glucose tolerance test (GTT) should be performed in women with PCOS and a BMI > 30 kg m2, with an assessment of the fasting and 2-hour glucose concentration (Table 39.2). It has been suggested that South Asian women should have an assessment of glucose tolerance if their BMI is greater than 25 kg m2 because of the greater risk of insulin resistance at a lower BMI than seen in the Caucasian population.

Fertility

Recent studies suggest that fertility in women with type 1 diabetes is the same as in women without diabetes. Polycystic ovary syndrome (PCOS) is a risk factor for type 2 diabetes, and women with this condition may have difficulty with ovulation and getting pregnant. Metformin, pioglitazone, and rosiglitazone can make the menstrual cycles regular and cause ovulation in women with polycystic ovary syndrome. Metformin is frequently used for this purpose, and the medication is stopped when the woman becomes pregnant.

Anovulation

WHO TYPE II (PCOS) Weight loss and dietary measures Weight loss should be the first line of treatment in obese women with anovulation due to PCOS. Central obesity and high BMI are important predisposing factors for insulin resistance, hyperinsulinaemia and hyperandroge-naemia. Effective treatment of obesity can reverse these effects and facilitate the effects of ovulation induction agents. In obese women with PCOS a loss of 5-10 of body weight may be enough to restore reproductive function in 55-100 women within 6 months (Clark et al. 1995). Clomifenecitrateis an orally activesynthetic non-steroidal compound with oestrogenic as well as anti-oestrogenic properties, which has traditionally been the treatment of choice in women with anovulatory PCOS. It displaces oestrogen from its receptors in the hypothalamic-pituitary axis, reduces the negative feedback effect of oestrogen and encourages GnRH secretion. It is administered in an initial daily dose of 50 mg on days 2-6 of a spontaneous...

Female

Virtually all ultrasound scanning in assisted conception is performed transvaginally. The initial scan assesses several areas (1) The ovarian morphology if there are underlying polycystic ovaries, they may be hyper-responsive to stimulation with gonadotrophins (see p.461) (2) The presence of ovarian cysts and if present suitable treatment arranged (3) Many centres now also measure the ovarian volumes as well as the antral follicle count as these are also used in the dose calculation of FSH for the stimulation phase of IVF (4) The ovaries are assessed for accessibility, not just for the monitoring itself but also if transvaginal oocyte retrieval (TVOR) is planned, to ensure that this can be performed without undue difficulty. Sometimes in patients who have abdominal adhesions (either from iatrogenic causes, previous pelvic inflammatory disease (PID) or endometriosis) then gentle abdominal pressure can be applied during the screening ultrasound to ensure that the ovary can be moved down...

Abbreviations

ACE, angiotension converting enzyme AGE, advanced glycation end-products AR, androgen receptor Akt, serine threonine protein kinase CNV, choroidal neovascularization COX, cyclooxygenase CVD, cardiovascular disease DHEA, dehydroepiandrosterone DHT, dihydrotestosterone DIEP, Diabetes in Early Pregnancy Study E, estrogens E2, 17p-estradiol EDRF, endothelium-derived relaxing factor ETDRS, Early Treatment of Diabetic Retinopathy Study eNOS, endothelial nitric oxide synthase ER, estrogen receptor ERa, estrogen receptor alpha ERp, estrogen receptor beta ERE, estrogen-response element ERK, extracellular signal-regulated kinases FGF, fibroblast growth factor HAM, hypoandrogen metabolic syndrome HDL, high-density lipoprotein HLA, human leukocyte antigen HRT, hormone replacement therapy HSP, heat-shock protein HUVEC, human umbilical endothelial cells IDDM, insulin-dependent diabetes mellitus, type 1 ICAM, inter-cellular adhesion molecule LDL, low-density lipoprotein LH, luteinizing hormone MAPK,...

Intersex disorders

Intersex Genitalia Pictures

These cases of masculinized genetic females are now rare. There are cases of androgen-secreting tumours that have occurred in pregnancy, which have resulted in virilization of the fetus, especially luteomy 25 , polycystic ovaries 26 and Krukenberg tumours 27 . The association between the use of progestogens and masculinization of the fetus is extremely rare.

Investigations

What Pipelle Endometrial Aspirator

The purpose of endometrial sampling in menorrhagia is to exclude or diagnose endometrial cancer or hyperpla-sia. Endometrial sampling is recommended in women aged more than 40 years and those with increased risk of endometrial malignancy. Significant risk factors for development of an endometrial carcinoma are obesity, diabetes mellitus, hypertension, chronic anovulation, nulliparity with a history of infertility, a family history of endometrial and colonic cancer and tamoxifen therapy 5 . In younger women endometrial sampling can also be indicated if abnormal bleeding does not resolve with medical treatment. In polycystic ovary syndrome in which endometrial

Infertility

Human Uterus And Polyps

With the presence of 12 or more follicles measuring 29 mm in one or both ovaries and an ovarian volume greater than 10 ml. 8 (Fig. 36.12). An ultrasound appearance of polycystic ovaries does not equate to a diagnosis of polycystic ovarian syndrome. This diagnosis can only be made if the patient is symptomatic. At present ultrasound is not recommended as a tool for assessing ovulation (NICE 2004).

Virilization

Acanthosis Nigrigans Vulva

Of the ovary or adrenal gland, Cushing's syndrome and late-onset congenital adrenal hyperplasia (CAH). While CAH often presents at birth with ambiguous genitalia (see Chapter 34), partial 21-hydroxylase deficiency may present in later life, usually in the teenage years with signs and symptoms similar to PCOS. In such cases testosterone may be elevated and the diagnosis confirmed by an elevated serum concentration of 17-hydroxyprogesterone (17-OHP) an abnormal ACTH stimulation test may also be helpful (250 p,g ACTH will cause an elevation of 17-OHP, usually between 65 and 470 nmol l).

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