[Music] polycystic ovary syndrome is a collection of signs and symptoms that result from having multiple abnormally developing follicles present in the ovaries it is known as an endocrinopathy which is a disease affecting the endocrine or hormonal system and is in fact the most common endocrinopathy in females of reproductive age thought to affect between 6 and 133% of females the exact mechanism behind posos is not well understood some evidence suggests involvement of the hypothalamic pituitary axis where normally the hypothalamus releases gonadotropin releasing hormone or GnRH that then stimulates the anterior pituitary gland to produce follicle stimulating hormone and lo lutenizing hormone which act on the ovaries ultimately causing them to produce androgens in posos a key feature is hyperandrogenism a proposed mechanism is that the hypothalamus produces rapid pulses of GnRH which leads to higher lutenizing hormone to follicle stimulating hormone which in turn then causes the ovaries to produce more androgens specifically testost erone and makes the adrenal glands more sensitive and release androgens more readily in response to adrenocorticotropic hormone these androgens then contribute to insulin resistance which is when tissues are less sensitive to the effect of insulin and so more insulin is needed to get the same response the trouble is that insulin also contributes to Androgen production from the ovaries and so this forms a vicious cycle on top of this insulin reduces production of sex hormone binding globulin from the liver which means that there are more free circulating androgens in the blood insulin and androgens both potentially modulate gonadotropin releasing hormone secretion and perpetuate the cycle the exact cause is unknown but it is thought to have a genetic component with heritability that is how much of the variation within a phenotype is down to genetics being roughly 70% but the exact genes involved have yet to be identified many of the features of posos are linked to the hyperandrogenism these include heroism in 60% which is the excessive growth of hair in a maleik pattern in females after puberty these are locations such as the face back and chest in particular acne is also common seen in around 20% of cases because androgens stimulate sebum production in the sebaceous glands the deranged insulin levels and sensitivity mean weight gain is common due to persistent higher glucose levels in the blood and increased appetite however peos can happen in people who are not overweight as well PTI patients with posos are also at higher risk of type 2 diabetes and cardiovascular complications irregular periods is another common symptom they are often infrequent defined as less than eight per year this can represent oligo or anovulation meaning reduced or no ovulation this can impair fertility but it is still possible to conceive with posos so contraception is still indicated if not wishing to get pregnant posos is also the most common cause of infertility in young females and is the underlying cause in 75% of females who have anovulatory infertility and features increased rates of gestational diabetes preeclampsia miscarriage and macrosomia for a diagnosis the Rotterdam criteria are used these include three features and two out of three need to be positive in adults and all three are required in teenagers these are clinical findings of hyperandrogenism or biochemical evidence of it which is typically a raised free Androgen index total and free testosterone note that this is generally mildly elevated very high readings May Point towards another diagnosis is and also that those on hormonal contraception should be offit for 3 months before these values are interpreted the second is oligo or an ovulation which often manifests as infrequent or reduced menstrual bleeding that is present for at least 2 years after manaki which is the first menstrual period posos can also be a cause for primary amena where there is a failure to reach manaki it's also worth noting that an ovulation can occur and still have some bleeding the third is ultrasound demonstrating polycystic ovaries defined as 12 or more follicles measuring two to 9 mm in diameter in one or both ovaries or increased ovarian volume Beyond 10 cm cubed note that in adolescence there is a high incidence of multi follicular ovaries on top of these Bloods should also be taken to rule out other causes 17 hydroxy progesterone to rule out 21 hydroxy deficient adrenal hyperplasia thyroid function tests for hypothyroidism and prolactin for hyperprolactinemia due to the increased cardiovascular risk posos patients will also require evaluation of blood sugars the gold standard being an oral glucose tolerance test and lipid levels there is no cure for polycystic ovary syndrome currently therefore management focuses on reducing symptoms maximizing fertility if the patient wants to conceive and preventing complications one of the most impactful management options is weight loss where a 5 to 7% loss in body weight can restore ovulation in 80% of females it's also Al helps interrupt the cycle of hyperandrogenism and insulin resistance and therefore usually helps to improve the hyperandrogenism symptoms as well the cardiovascular benefits of weight loss are also well known medication is an option in those not wanting to conceive an oral contraceptive pill is frequently used as it helps to reduce GnRH secretion and increases sex hormone binding globulin the progesterone component also helps to prevent endometrial cancer and abnormal uterine bleeding in this group metformin is commonly used though the evidence for it is variable aromatase Inhibitors like elol have been shown to increase rates of live births while anti-androgen therapies like finasteride a 5alpha reductase inhibitor and spironolactone an androgen receptor blocker may be helpful for symptomatic control in cases where they are not trying to conceive given that these are teratogenic antibiotics and retinoids are also possibilities for acne overall it's a condition with multiple components which may need a multi-pronged approach