Polycystic ovarian syndrome: diagnosis and management

Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women of reproductive age. The lack of well-defined diagnostic criteria makes identification of this common disease confusing to many clinicians. Also, with the varied manifestations of the disorder a patient may present to any one of several providers: an internist, family practitioner, nurse practitioner, pediatrician, gynecologist, dermatologist, or endocrinologist. Furthermore, the most distressing aspect of PCOS for any given patient may change over time, from hirsutism as a teenager to infertility as a young adult--potentially requiring several different providers along the way. It is important, therefore, that those caring for these patients understand not only the management issues pertinent to their specialty, but also appreciate the other potential health risks in these women. Recent insights into the pathophysiology of PCOS have shown insulin resistance to play a substantial role and as such have brought the long-term issues of type 2 diabetes mellitus and its resultant increased risk of coronary artery disease to the forefront. No longer can irregular menses and/or hirsutism be thought of as benign nuisances. This review will focus on the two most confusing aspects of PCOS for the practicing provider--diagnosis/differential diagnosis and treatment options. Special attention is given to the role of insulin resistance and the potential utility of insulin sensitizers in management. The benefit and utmost importance of lifestyle modification for the long-term health of these women is stressed as well. It is hoped that some clarity in this regard will allow more women to not only be diagnosed and managed properly for their presenting symptoms (hirsutism, irregular menses, etc.), but also to be educated and managed for the continuing health risk of insulin resistance throughout their lives.     

Polycystic ovary syndrome [PCOS]: comprehensive management in primary care

Polycystic ovary syndrome is a common premenopausal endocrino-metabolic disorder. In addition to hyperandrogenism, menstrual abnormalities, ovulatory disturbances and infertility, insulin resistance, dyslipidemia, and obesity may eventuate in long-term cardiovascular consequences. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article.     

Polycystic ovary syndrome: implications for the advanced practice nurse in primary care

PURPOSE: To discuss the diagnosis and management of polycystic ovary syndrome (PCOS) by the advanced practice nurse in primary care. DATA SOURCES: Selected research and clinical articles. CONCLUSIONS: The disorder is an endocrinopathy characterized by chronic anovulation, resulting in multiple ovarian cysts. Recent research suggests a genetic etiology and a close association with obesity. Patients often present with hyperandrogenism, irregular menses, and infertility. Management is directed at the alleviation of individual symptoms. IMPLICATIONS FOR PRACTICE: If left untreated, cardiovascular disease, abnormal insulin metabolism, and ovarian and endometrial cancers may develop.     

多囊卵巢综合征与脂类代谢异常

多囊卵巢综合患者（PCOS）可出现不同程度的脂类代谢异常，主要与肥胖、高胰岛素血症、高雄激素血症等因素密切相关，治疗方面需要在调整生活方式的基础之上，利用药物减少胰岛素抵抗，降低高雄激素血症。     

Polycystic ovary syndrome: a review for primary providers

PCOS is a metabolic syndrome that exists throughout the world with much clinical heterogeneity. PCOS is now appreciated as encompassing two interrelated metabolic phenomena--insulin resistance and hyperandrogenism. Patients present with oligo-amenorrhea and clinical hyperandrogenism, and the diagnosis is based on clinical grounds with few laboratory tests necessary. Because patients are at higher than normal risk for diabetes, glucose intolerance, and hyperlipidemia, and perhaps at higher risk for coronary heart disease, newly diagnosed patients with PCOS should be evaluated for glucose intolerance and hyperlipidemia. The cornerstone of therapy today includes weight management, and further therapeutic intervention is focused on reproductive and cardiovascular health and treatment of insulin resistance. Clinical case continued The 17-year-old mentioned in the beginning of this article probably does have PCOS. She fits the clinical criteria: oligo-ovulation and hyper-androgenism (the acne and hirsutism). In addition, she is obese, which is also associated with PCOS. Her TSH and prolactin were normal, and as her presentation was not suggestive of an adrenal tumor or congenital adrenal hyperplasia (she had mild hirsutism, and those diagnoses are associated with more severe hyperandrogenism), no further laboratory evaluation was deemed necessary. Once the diagnosis was made, she was screened for lipid abnormalities and for glucose intolerance. Her LDL was 150, HDL 35; oral glucose tolerance test (OGTT) was normal. A pregnancy test was negative, and she was started on OCPs. Devoting herself to exercise and dietary change, she lost 10 pounds in her first 3 months after diagnosis. Her hirsutism and acne have improved with the OCPs and weight loss, and her menses are regular. She has elected to defer oral insulin sensitizers until her weight loss has stabilized. Findings PCOS is common in reproductive-aged women. Diagnosis is clinical and is supported by lab findings; there is significant clinical heterogeneity. Insulin resistance is likely central to the pathophysiology along with androgen excess. Health implications include infertility, diabetes, endometrial cancer, hyperlipidemia, and possibly coronary heart disease. Treatment is evolving and includes weight loss, OCPs, and insulin sensitizers.     

Polycystic ovarian syndrome: assessment with color Doppler angiography and three-dimensional ultrasonography.

We conducted a three-dimensional ultrasonographic evaluation of the size and structure of the ovaries of women who had clinical and biochemical findings suggestive of polycystic ovary syndrome. We carried out a comparative color Doppler frequency and color Doppler amplitude study of the vascular patterns of these ovaries. This study involved 65 women of reproductive age with polycystic ovary syndrome and 25 eumenorrheic women who were not taking hormonal contraceptives and who had a body mass index below 25 kg/m2. Compared to controls, women with polycystic ovary syndrome had larger ovaries and thicker stroma, increased impedance in the uterine arteries, increased stromal vascularity with decreased impedance that persisted throughout the menstrual cycle, and a lack of luteal conversion.     

Issues in the diagnosis of Cushing's syndrome for the primary care physician

The diagnosis of Cushing's syndrome is one of the most difficult and yet one of the most important ones a primary care physician can make. The clinical presentation overlaps that of many other common diseases, but more specific signs such as unexplained osteoporosis, muscle weakness, ecchymoses, hypokalemia, and central obesity, the presence of multiple symptoms affecting different body systems, and a demonstrated change over time should prompt the screening evaluation. We recommend a step-wise approach to the diagnostic evaluation. Step 1 involves demonstrating pathologic hypercortisolemia and thus making the diagnosis of Cushing's syndrome. In step 2, distinguishing ACTH-independent disease from ACTH-dependent disease and then adrenal imaging is done. Finally, for patients with ACTH-dependent disease, step 3 entails anatomic localization of the ACTH source by MRI, if unequivocal, or by IPSS or CSS. Only when the evaluation is done in a step-wise fashion can the clinician be assured that appropriate treatment recommendations can be made. Although a fair amount of the testing is complex, requiring special facilities and usually the assistance of an endocrinologist, the most critical step is that done by the primary care physician--considering the diagnosis and initiating the screening algorithm.     

Postpartum disorders in primary care: diagnosis and treatment

Postpartum psychiatric illness consists of a highly prevalent group of disorders, which can result in serious dysfunction and require treatment. Patients are more likely to seek help for these disorders from their primary care physicians rather than mental health professionals. While severe postpartum depression and psychoses are easily recognized, milder or more insidious forms of depressive illness frequently are missed. Heightened sensitivity to and screening for the presence of these prevalent psychiatric disorders facilitates and enhances recognition of postpartum disorders and leads to more expeditious treatment.     

Conduct disorder: diagnosis and treatment in primary care

Conduct disorder is a common childhood psychiatric problem that has an increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at least a six-month period. Conduct disorder has a multifactorial etiology that includes biologic, psychosocial and familial factors. The differential diagnosis of conduct disorder includes oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), mood disorder and intermittent explosive disorder. Family physicians may provide brief, behaviorally focused parent counseling, pharmacotherapy and referral for more intensive family and individual psychotherapy.     

Novel approaches to the diagnosis of basal cell nevous syndrome

In 1960, Robert James Gorlin and William Goltz, both American physicians, defined a new syndrome. Little did they realize that 40 years later, the pathways involved in its development would be provoking serious and sustained interest amongst a plethora of specialists. Fruit-fly biologists, oncologists, geneticists, dermatologists, indeed, hardly a medical or dental specialist gets excluded. To date, there have been some major breakthroughs in identifying abnormal gene sequences. Much has been discovered about this syndrome and its pivotal role in a number of cancer pathways but much more waits to be done or explained. This article sets out to discuss the current position and aims to stimulate further work on this intriguing and puzzling disorder.