The Surgical Management of Polycystic Ovarian Syndrome

Abstract

Polycystic ovarian syndrome (PCOS) is defined by ultrasound appearance of polycystic ovaries (PCO), enlarged ovaries with at least 10 peripherally located follicles measuring between 2 and 10 mm, associated with symptoms of oligo-amenorrhoea, obesity and hyperandrogenism (acne and hirsutism) [1]. Stein–Leventhal syndrome was described in 1935 as a condition of obese women with amenorrhoea, signs of excess androgen production and bilateral enlarged, polycystic ovaries [2]. Many women with ultrasound detected PCO do not have the typical triad of symptoms and hence do not have PCOS. Raised serum luteinising hormone (LH) and raised androgens such as testosterone are the endocrine markers of PCOS and are associated with menstrual irregularity and infertility [3]. Increased androgen production in particular increased serum testosterone, LH and free androgen index, along with lower serum glucose/insulin ratios and lower sex hormone binding globulin (SHBG) are linked to disrupted folliculogenesis. Insulin resistance lies at the heart of the metabolic effects of PCOS. Women presenting with hirsutism and oligomenorrhea have the highest correlation with the metabolic markers of PCOS. These symptoms are markers of the underlying metabolic alterations possibly associated with increased health risks in later life. [4]. There is controversy surrounding hypersecretion of LH and infertility and miscarriage. The relation between pre-pregnancy follicular-phase serum luteinising hormone (LH) concentrations and outcome of pregnancy was investigated prospectively in 193 women with regular spontaneous menstrual cycles. The group of women with LH concentrations of less than 10 IU/l (normal LH group) had a lower miscarriage rate compared to the group of women with a higher early follicular phase LH level, more than 10 IU/l. This study concluded that there was an important association between hypersecretion of LH and miscarriage [5]. Other studies have examined the link between raised LH and miscarriage [6]. It has been proposed that treatments which decrease LH concentrations, such as gonadotrophin-releasing hormone analogues or laparoscopic ovarian diathermy, improve induction of ovulation and pregnancy rates and reduce miscarriage rates. Tonic hypersecretion of LH appears to induce premature oocyte maturation, causing the problems with fertilisation and miscarriage [7].