Polyendocrine Metabolic Ovarian Syndrome

Previously known as Polycystic Ovarian Syndrome (PCOS)

Diagnosis, 2/3 of the following:

• Oligo-ovulation/anovulation (LH:FSH >2)

  • Oligomenorrhea (>35d) or amenorrhea

• Hyperandrogenism (clinical or biochemical)

  • Acne, androgenic alopecia, hirsutism (terminal hairs >5mm)

    • • Consider modified Ferriman-Gallwey score (mFG) of 4-6 should be used to detect hirsutism, depending on ethnicity

  • Elevated serum total/bioavailable/free testosterone or DHEAS

• Polycystic ovaries on ultrasound

Consider waiting 8 years post-menarche before diagnosing PMOS, given likelihood for physiological anovulation of adolescence

Investigations

• b-hCG, Prolactin, TSH, FSH/LH

• If no clinical hyperandrogenism, Serum total/bioavailable/free testosterone

  • If normal, may consider repeat testing, preferably early morning or measuring androstenedione and dehydroepiandrosterone sulfate (DHEAS)

    • Combined OCP may decrease androgen production, consider holding OCP for three months if test is important

• If not met criteria already for diagnosis, can do Pelvic ultrasound (Follicle number per ovary (FNPO) ≥ 20 in at least 1 ovary)

Consider endocrine work-up

• • If rapidly progressive hirsutism, lowering of the voice, and clitoromegaly

    • DHEAS >700mcg/dL, r/o virilizing tumour

    • Morning 17OHP >170ng/dL, r/o CAH or virilizing tumour

    • Abdo/Pelvic ultrasound, r/o adrenal/ovarian tumor

  • If central obesity, striae, proximal myopathy, early osteoporosis/hypertension

    • Mid-day/afternoon Cortisol, r/o Cushing's

      • If elevated, consider 24-h urine collection for free cortisol and creatinine

  • If acromegaly features,

    • IGF-1, r/o acromegaly

Management

• Monitor for diabetes, dyslipidemia, hypertension, weight (BMI)

• Healthy active lifestyle, diet, Weight management first-line

• Laser and light therapies for hirsutism

• Combined OCP for hyperandrogenism, irregular menses , contraception

  • For hirsutism, if OCP not effective after 6 months, consider adding Spirinolactone 50-100mg/day 

• If desires pregnancy, target of BMI <35 and/or 5% to 10% weight loss

  • Letrozole first-line medication for infertility

  • Clomiphene citrate 

  • Metformin

  • Gonadotrophins

  • Laparoscopic ovarian surgery

  • IVF, IVM