Obesity and women’s health 2: polycystic ovary syndrome

My name is Dr. Thom Barber. I'm an Associate Professor and Honorary Consultant Endocrinologist based at the University of Warwick in UK and UHCW NHS Trust. So in the second part of this talk, I'm going to specifically talk about Polycystic Ovary Syndrome, which is a very common condition affecting pre-menopausal women and a condition which is very closely associated with obesity.

In this part of the talk, I will firstly consider what is PCOS. I'll talk about its pathogenesis, genetic corroboration with obesity, links with obstructive sleep apnea and then consider specifically whether having PCOS may make it harder to lose weight and also use of metformin therapy in women with PCOS.

So what is Polycystic Ovary Syndrome?

Some historical aspects. In 1921, Archard and Thiers first made a link between hirsutism and metabolic derangements in their description of a bearded lady with diabetes. But it wasn't until 1935 when Stein and Leventhal first described the syndrome of PCOS. But it really wasn't until much more recently in 1980 when we realized that Polycystic Ovary Syndrome is actually an insulin resistant condition and a condition which is associated with multiple dysmetabolic features. And since then, of course, there has been much research into the cardiometabolic associations of PCOS.

What is Polycystic Ovary Syndrome? A couple of diagnostic criteria which I used, and on the right is shown the NIH criteria from 1990. And the NIH criteria defined PCOS as presence of both hyperandrogenic features in addition to chronic anovulation. Hyperandrogenic features are defined by either chemically, mainly through increased levels of testosterone or free androgen index, for example. Clinically, and the main clinical manifestations include, for example, hirsutism, androgenetic alopecia and acne. In 2003, the NIH criteria was superseded by Rotterdam criteria which used two of three ruled and the three criteria are defined as, number one, Polycystic ovarian morphology, which is defined presence of at least 12 follicles of between 2 and 9 millimeters in diameter in either ovary or an ovarian volume of at least 10 milliliters in either ovary. Oligo-amenorrhoea is the second criteria and this is an inter-menstrual interval of at least 42 days. And finally, as with the NIH criteria, hyperandrogenism, which again defined either biochemically, and, or clinically in terms of hirsutism definition and this is defined as the Ferriman-Gallwey score of at least eight or the need for at least weekly cosmetic treatments of hirsutism. Now importantly, Polycystic Ovary Syndrome is a diagnosis of exclusion. There are many conditions which can masquerade as PCOS and many conditions are associated with hirsutism, for example, under oligo-amenorrhoea in women. And some of these are shown here, for example, Cushing's syndrome, acromegaly, congenital adrenal hyperplasia, hyperprolactinemia, adrenal and ovarian tumors which cause hyperandrogenaemia. And of course, it's important to exclude these other conditions before we diagnose a woman with PCOS. In terms of Cushing's and acromegaly, we only tend to screen for these biochemically if there clinical features of these syndromes, but looking for a 17-hydroxyprogesterone can be quite useful to exclude CAH, for example. And prolactin level should be a part of the biochemical workup as well. As a general rule of thumb, if testosterone levels are above 5 nanomoles per liter, then we would then need to look for an adrenal and ovarian origin with scanning to exclude any tumor of the adrenal gland or ovaries.