Polycystic Ovary Syndrome and Hirsutism

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Chapter 546 Polycystic Ovary Syndrome and Hirsutism

Mark Gibson, Heather G. Huddleston

Polycystic Ovary Syndrome

Etiology and Definition

Polycystic ovary syndrome (PCOS) is a common disorder of reproductive hormone dysfunction, often with associated metabolic abnormalities, that affects 5-8% of women of reproductive age. The disorder typically emerges in adolescence when a normal menstrual pattern is not established and there is clinical evidence of androgen excess. It is characterized by the triad of oligo-ovulation or anovulation, clinical or biochemical hyperandrogenism, and ovarian cysts (≥12 immature follicles) (the Rotterdam criteria). Various expert bodies prioritize these elements differently for establishing the diagnosis, and few require the presence of all 3. Hyperandrogenism with ovulatory dysfunction (with exclusion of other causes) is most often considered sufficient for diagnosis in the USA. Abnormalities commonly associated with PCOS include obesity, insulin resistance, and the metabolic syndrome, but the phenotype is variable (see Table 546-1 on the Nelson Textbook of Pediatrics website at www.expertconsult.com).

Table 546-1 PHENOTYPES FOR POLYCYSTIC OVARY SYNDROME (PCOS) BASED ON 2003 ROTTERDAM CRITERIA

Pathology Pathogenesis and Genetics

PCOS has a high concordance rate in twins, and in some studies either epigenetic or dominant inheritance patterns are observed. Nonetheless, a consistent hereditary pattern has not been identified.

Gonadotropic dysregulation with increased luteinizing hormone (LH) pulsatility and abnormally high ratios of circulating LH to follicle-stimulating hormone (FSH) are found in many patients with PCOS. Increased ovarian production of androgen in response to LH and impaired folliculogenesis owing to lower FSH are attributed to this gonadotropic pattern. Abnormal regulation of gonadotropin-releasing hormone agonist (GnRH) and abnormal gonadotropin secretion more likely reflect the abnormal hormonal milieu of the syndrome than explain its origin (Fig. 546-1). An increased ratio of circulating levels of LH to FSH is not a diagnostic criterion for PCOS.

Figure 546-1 Schematic of pathophysiology of polycystic ovary syndrome and mechanism of therapeutic drugs. DHT, dihydrotestosterone; LH, luteinizing hormone; SHBG, sex hormone binding globulin; OCPs, oral contraceptive pills.

(Adapted from Hassan A, Gordon CM: Polycystic ovary syndrome in adolescence, Curr Opin Pediatr 19[4]:389–397, 2007.)

Alterations in activities of steroidogenic enzymes that would explain ovarian androgenic hyperfunction are seen in PCOS subjects, but they are not consistently present in all patients; it is unclear whether these alterations cause PCOS or are a consequence of ovarian dysregulation. The mass of ovarian stromal cells responsible for androgen production is increased, and surgery that reduces this ovarian component (ovarian wedge resection, or laparoscopic ablative procedures) reduces circulating androgen levels and often restores ovarian cyclicity. Patients with hyperandrogenic congenital or adult-onset adrenal hyperplasia exhibit PCOS-like ovarian dysfunction that can be reversed by reducing the adrenal-derived androgens with glucocorticoid therapy. A primary role for androgen excess in the pathophysiology of all instances of PCOS seems unlikely; many patients have minimal hyperandrogenism, and elimination of androgen excess (with GnRH agonists) does not affect associated insulin resistance.

Measures of insulin resistance are greater and more prevalent among women with PCOS than controls even when accounting for BMI. Insulin enhances ovarian androgen production directly and contributes to elevations of free testosterone levels through its suppression of hepatic production of sex steroid–binding globulin. Treatment with insulin sensitivity–enhancing agents that can reduce insulin levels is associated with modest reductions in measures of androgen excess and, in some patients, restoration of regular ovulation. The association of insulin resistance with weight might explain the appearance of features of PCOS among some women who gain weight and the resolution of PCOS among affected women who lose weight.

PCOS commonly becomes manifest as puberty progresses, but its onset can occur later during young adulthood. PCOS is a lifelong disorder (though with some evidence for amelioration with age or weight loss) (Table 546-2). Clinical hallmarks are menstrual abnormalities and manifestations of hyperandrogenism. Ovulation is typically irregular or absent, and menses are consequently irregular or absent. When they do occur, menses may be relatively normal in character as a consequence of a preceding ovulation. In many women, protracted periods of unopposed estrogen exposure without ovulation can terminate erratically in bleeding that is abnormally prolonged and/or heavy.

Table 546-2 LIFELONG HEALTH COMPLICATIONS

PRENATAL OR CHILDHOOD	ADOLESCENCE, REPRODUCTIVE YEARS	POSTMENOPAUSAL
REPRODUCTIVE
Premature adrenarche Early menarche

Menstrual irregularity

Pregnancy complications

Delayed menopause? METABOLIC Abnormal fetal growth

Obesity

Impaired glucose tolerance

Impaired glucose tolerance

OTHER

Cardiovascular disease?

From Norman RJ, Dewailly D, Legro RS, et al: Polycystic ovary syndrome, Lancet 370:685–696, 2007.

The diagnosis of PCOS in adolescents may be made on the basis of a lack of resolution of the normal pattern of anovulatory menstrual cycles present in the first 1 or 2 postmenarcheal years. Less commonly, the diagnosis is made in the setting of primary amenorrhea. Serum androgen levels may be elevated and clinical findings of androgen excess are common, though distinction of normal androgenic expressions of puberty (acne, mild hirsutism) from early manifestations of PCOS may be difficult.

Obesity is common among affected women, and in some patients expression of PCOS features is conditional on elevation of BMI and reversible with weight loss. A subset of patients present with a “lean” PCOS phenotype; absence of excess weight should not preclude consideration of the PCOS diagnosis. PCOS is associated with an increased prevalence of insulin resistance and type 2 diabetes independent of the tendency for many affected patients to have an elevated BMI. Additionally, PCOS confers a substantial and specific increase in risk for metabolic syndrome (hyperlipidemia, insulin resistance, type 2 diabetes) in adolescent girls after accounting for BMI.

Laboratory Findings, Diagnosis, and Differential Diagnosis

The diagnosis of PCOS requires exclusion of disorders that would otherwise account for hyperandrogenism and anovulation. Serum 17-hydroxyprogesterone should be measured when there is clear androgen excess to screen for adult-onset 21-hydroxylase deficiency (Chapter 570). In the adolescent with amenorrhea but minimal hyperandrogenic findings, consideration should be given to functional hypothalamic suppression due to excessive exercise and/or dieting and a careful history taken to rule out such behavioral patterns. All patients should be clinically evaluated for Cushing syndrome, and biochemical evaluation is indicated when findings, including hypertension and/or characteristic body habitus features, are suggestive (Chapter 571). The two disorders have in common a tendency for overweight and varying degrees of insulin resistance and androgen excess, but they differ in that Cushing syndrome demonstrates muscle wasting as a result of catabolism.

Evidence for androgen excess that is rapid in onset and/or severe, especially if masculinizing, warrants measurement of androgens (total testosterone, dehydroepiandrosterone [DHEAS]) to exclude evidence of an androgen-secreting adrenal or ovarian tumor. The laboratory evaluation is completed with the exclusion of hyperprolactinemia, premature ovarian failure, and thyroid disease as causes of anovulation: determinations of functional hyperprolactinemia (hPrl), FSH, and thyroid-stimulating hormone (TSH), respectively.

The diagnosis of PCOS is confirmed from the constellation of oligo-ovulation or anovulation, androgen excess (clinically or with biochemical confirmation), and typical ovarian cysts on ultrasound. Various experts weigh these 3 features differently and do not, as a rule, require the presence of all. Young women often exhibit the ovarian appearance of PCOS without any other evidence, and not all patients with PCOS by the criteria of hyperandrogenism and ovulatory disruption exhibit ovarian changes typical of PCOS. Ultrasound study to diagnose PCOS is not always required if oligo-ovulation and features of androgen excess are present. Clinical androgen excess (acne; mild or idiopathic hirsutism) often appears in late puberty and does not necessarily signal PCOS. Nevertheless, young women with persistent oligo-ovulation or anovulation, and also those with androgen excess, likely have persistence of these symptoms and should be considered to have PCOS.

Insulin resistance is common among women with PCOS, and though not requisite for diagnosis, it should be sought when PCOS is likely. Adolescents with hyperandrogenemia and anovulation should be evaluated for diabetes or impaired glucose tolerance with a 2-hour (75 g glucose load) glucose tolerance test, especially if they are obese.

Complications and Long-Term Outlook

Fertility management, prevention of endometrial cancer, and reduction in the likelihood and severity of the common accompanying metabolic disorders are long-term tasks for the PCOS patient and her health care providers (see Table 546-2). Notwithstanding its reversibility with weight loss in some patients and a tendency to ameliorate in some women later in reproductive life, PCOS usually requires management throughout the reproductive years. Young patients should be counseled that modern fertility management allows most affected women to have children without great difficulty, and they should also know that the disorder does not confer reliable protection from unintended pregnancy. Endometrial cancer can develop as early as the 3rd decade in women with PCOS who are not managed with progestins or ovulation induction; patients should understand the importance of long-term strategies for endometrial protection. Impaired glucose tolerance, type 2 diabetes, and metabolic syndrome are more common among obese adolescents with PCOS; their prevalence increases over time. Weight control through diet and lifestyle measures, detection and management of impaired glucose tolerance and diabetes, and management of abnormal lipids are targets for long-term management.

Treatment

Management focuses on the menstrual abnormalities, symptoms of androgen excess, and associated metabolic changes. Weight loss through lifestyle change, use of hormonal contraceptive agents for menstrual regulation as well as androgen suppression, antiandrogens as adjuncts for hirsutism treatment, and insulin-sensitizing agents are common components of treatment.

Lifestyle Changes

Several studies have shown that comprehensive lifestyle programs for overweight and obese women with PCOS aimed at fitness and weight loss can yield high rates of restoration of normal menstrual function, reduction of free androgen index, reduction in measures of insulin resistance, and improvements in serum lipids. Limited data show similar benefits from such interventions for obese adolescents with PCOS.

Hormonal Contraceptives

Combined (estrogen and progestin) hormonal contraceptive medications are considered first-line therapy for adults not desiring fertility and for adolescents (Chapter 111). Adolescents with PCOS are at risk for unintended pregnancy; their fertility would be expected to be reduced relative to peers’, but they are still at risk for pregnancy.

Avoidance of hyperplastic endometrial states due to unopposed estrogen and management of abnormal uterine bleeding in anovulatory episodes can be accomplished with the use of combined hormonal contraceptives. The progestational component inhibits endometrial proliferation and the schedule of pill administration predictably regulates menstrual bleeding. The estrogenic component of combined oral contraceptive elevates circulating sex-hormone binding globulin (SHBG), which reduces free and bioavailable testosterone levels. Both hormonal elements combine to suppress gonadotropic (particularly luteinizing hormone) stimulation of ovarian androgen production. DHEAS levels, often contributory to hyperandrogenemia in PCOS, are usually decreased by combined contraceptive use. Products with less-androgenic progestational components (drospirenone, desogestrel) can provide better relief from androgenic symptoms.

Using a product that is well tolerated in long-term use is more important than using a product with particular progestational component. Products with reduced frequency and duration of pill-free intervals can provide superior androgen suppression and a welcome decrease in frequency of bleeding episodes. Depot medroxyprogesterone acetate for contraception, endometrial protection, and androgen suppression may be a suitable alternative to combined hormonal contraceptives; it provides even more profound suppression of ovarian hormonogenesis, but it does not elevate SHBG. Low-dose progestin-only regimens (oral minipills, implantable progestational contraceptives, and progestin-releasing IUDs) also provide effective endometrial protection but would be expected to provide only partial and/or inconsistent androgen suppression, would not elevate SHBG, and have not been shown to be consistently helpful in regard to abnormal bleeding patterns.

Patients without the need for management of hyperandrogenic symptoms or contraception are often treated with periodic use of oral progestins to induce predictable menstrual bleeding and prevent endometrial hyperplasia and malignancy. Twelve-day courses of medroxyprogesterone acetate 10 mg daily or norethindrone acetate 5 mg daily are effective and safe for this purpose when taken every 1-2 mo.

Metformin

Metformin is a biguanide medication used to treat type 2 diabetes, its only FDA-approved indication. It has been used in a variety of settings and with differing objectives for patients with PCOS. Metformin exerts its principal effect by reducing hepatic production of glucose and limiting intestinal absorption of glucose. Studies have shown that a subset of women with PCOS resume regular ovulation and menses when treated with metformin, obviating the need for progestational therapy or ovulation-induction medications to protect endometrial health. For some patients the resulting normal reproductive function is appealing regardless of interest in fertility.

Metformin reduces insulin resistance and the levels of androgens. Its extended use can reduce the likelihood of development of impaired glucose tolerance or the progression of impaired glucose tolerance to type 2 diabetes; these effects are not yet proved for patients with PCOS. It should not be used in the presence of renal or hepatic impairment. Typical dosing is 1500 to 2000 mg/day, achieved through gradual increments because gastrointestinal (GI) intolerance is common. Long-acting preparations are helpful when GI intolerance is a problem.

The use of metformin in the treatment of PCOS depends on the patient’s goals and preference. For the treatment of hyperandrogenic symptoms, metformin effects may be modest compared to other available agents There are no empirical data supporting the theoretical benefits of long-term use of metformin in adolescents with PCOS and obesity compared to the outcomes achieved with weight loss and oral contraceptive medications. Use of metformin as a first-line agent is favored by some experts, in part for improvement in serum measures of intermediate outcomes, and in part because of evidence in other populations of reduced progression of insulin resistance. There is no evidence for long-term benefit to clinical outcomes of adding metformin to treatment for women managed primarily with oral contraceptives. For adolescents receiving metformin as a first-line medication, progestational management (combined contraceptives or periodic progestins) will still be necessary for those not resuming ovulatory function, contraception, and/or additional antiandrogen management.

Antiandrogens

Antiandrogenic medications may be added to other therapies or used alone for the treatment of hirsutism. These agents are usually used integrally or adjunctively with ovarian hormonal suppression, in part because of better reduction in hirsutism when antiandrogens are combined with ovarian suppression but also to reduce the risk of unintended embryonic or fetal exposure. The highly active androgen antagonist and progestin, cyproterone, is available in Europe and in Canada as a single agent for treatment of hirsutism or in combination with ethinyl estradiol as an oral contraceptive with enhanced antiandrogenic profile. In the USA, spironolactone is the most commonly used antiandrogen. Spironolactone antagonizes androgens at their receptor and also impairs androgen synthesis. Doses of 100-200 mg daily are commonly used. Other agents that have been studied are finasteride, a 5α-reductase inhibitor, and flutamide, a nonsteroidal and highly specific androgen receptor antagonist. These are rarely used because of lack of evidence of superior effectiveness, cost, and, in the case of flutamide, the potential for hepatotoxicity.

Hirsutism

Hirsutism is defined as abnormally increased terminal (mature, heavy, dark) hair growth in areas of the body where hair growth is normally androgen dependent (Chapter 654). Its presence is a result of the combination of extent of androgenic stimulation and familial regional follicle sensitivity to androgens, which varies considerably among ethnic groups. Patients’ cosmetic concerns generally determine whether findings of hirsutism are a matter for clinical investigation and treatment. Hirsutism as an isolated finding is to be distinguished from masculinization. The latter includes alteration in muscle mass, clitoral enlargement, and voice change, generally manifesting as a rapid evolution (over months). Masculinization mandates a search for neoplastic source of androgen. Elevations of testosterone or DHEAS commonly indicate an ovarian or adrenal androgen source, respectively; specific imaging and occasionally selective catheterization studies are indicated.

Hirsutism without masculinization is common. The potential causes to consider are PCOS (when there is hyperandrogenism and anovulation), benign functional androgen excess (measurable hyperandrogenism without anovulation), idiopathic hirsutism (increased hair in androgen-dependent areas without measurable androgen excess), and adult-onset adrenal hyperplasia (Table 546-3). Patients can be primarily distinguished by evidence of ovulatory disorder by menstrual history, and for those with absent or irregular menses, a diagnosis of PCOS can be made. The remainder, for whom adult-onset adrenal hyperplasia and PCOS have been excluded, either have normal androgen levels with enhanced end-organ sensitivity owing to familial or ethnic predisposition or have a functional and benign overproduction of ovarian androgens. Measures of androgens (testosterone, DHEAS) may be normal or mildly elevated in the latter group. Testosterone suppresses circulating sex-steroid binding globulin, so that states of testosterone overproduction might not be accompanied by elevated measures of total testosterone although estimates of “free” or “bioavailable” testosterone reveal hyperandrogenism. Measures of unbound testosterone distinguish idiopathic hirsutism from mild benign hyperandrogenic states; making this distinction contributes little to patient management and adds cost. Idiopathic hirsutism (without evidence of androgen excess) usually responds to antiandrogen or androgen suppression therapy similarly to hirsutism associated with elevated androgens and anovulation (PCOS), and benign hyperandrogenism not associated with PCOS.

Table 546-3 CAUSES OF HIRSUTISM

PERIPHERAL

Idiopathic

Partial androgen insensitivity (5α-reductase deficiency)

HAIR-AN syndrome (hirsutism, androgenization, insulin resistance, and acanthosis nigricans)

Hyperprolactinemia

GONADAL

Polycystic ovary syndrome (polycystic ovaries, chronic anovulation)

Ovarian neoplasm (Sertoli-Leydig cell, granulosa cell, thecoma, gynandroblastoma, lipoid cell, luteoma, hypernephroma, Brenner tumor)

Gonadal dysgenesis (Turner mosaic with XY or H-Y antigen positive)

ADRENAL

Cushing syndrome