MyPACS.net: Radiology Teaching Files > Case 65050973

Last visited 06/29/2013 Hirsuitism, obesity and irregular periods
Contributed by: Jason Hoskins, Resident, SAMMC, Texas, USA.
Patient: 24 year old female
History: 24 year old female with hirsutisim, BMI 33, and irregular periods.  Please evaluate ovaries.
Images:[small]larger

Fig. 1: Sagittal uterus - normal size with proliferative phase endometrial stripe 7mm- overall normal

Fig. 2: Rt ovary sagittal - enlarged ovary with greater than 12 peripheral small anechoic cysts of similar size and increased through transmission

Fig. 3: Rt ovary sagittal - enlarged ovary with greater than 12 peripheral small anechoic cysts of similar size and increased through transmission - this one has a "string of pearls" appearance

Fig. 4: Lt ovary coronal - enlarged ovary with greater than 12 peripheral small anechoic cysts of similar size and increased through transmission

Fig. 5: Lt ovary sagittal - enlarged ovary with greater than 12 peripheral small anechoic cysts of similar size and increased through transmission
Findings:

The uterus measures 6.4 cm. Normal echogenicity. Endometrial stripe measures 7 mm.

The ovaries are normal in size and echotexture. The right ovary measures 4.6 x 1.8 x 3 cm with a volume of 12.9 mL. The left ovary measures 3.0 x 2.0 x 3.4 cm with a volume of 11 mL. There are too numerous to count peripheral, symmetric small anechoic cysts in both ovaries. No free fluid.

SUMMARY: Too numerous to count peripheral, symmetric small anechoic cysts in both ovaries.

Diagnosis: Findings supporting PCOS - pt recently diagnosed with clinical PCOS.
Discussion:

Polycystic ovary syndrome is associated with chronic anovulation, multiple small, nonfunctioning cysts and hypoandrogenism.  When findings combined with amenorrhea, hirsuitism, infertility and obesity, it is called Stein-Leventhal syndrome (far end of PCOS spectrum). 

The revised 2003 Rotterdam consensus imaging criteria for ultrasound in PCOS include: enlarged (>10mL) ovaries with multiple (>12), small follicles measuring 2-9mm.    There should be no dominant follicle >10 mm or corpus leuteum cyst and only one ovary may have this appearance and still support the dx. 

Not included in the Rotterdam criteria but classically these follicles are usually less than 5mm and arranged peripherally in a "string of pearls" configuration.  The ovaries are usually more rounded with a prominent central stroma and may have a bight, thick hyperechoic capsule.  However, ovaries may be normal or large and solid and still meet  the patient may meet the clinical diagnosis.

Abnormalities associated with PCOS - insulin resistance (type 2 diabetes) and hypertension with altered lipid profile.  Increased risk of endometrial cancer becuase of chronic anovulation with unopposed estrogen stimulation of endometrium

PCOS occurs due to hypersecretion of leutinizing hormone (LH) and a low level of follicle stimulating hormone (FSH) which leads to follicles that remain in suspended development.  Estrogens are elevated due to conversion of androgens from the elevated LH. These elevated estrogens, combined with low progesterone lead to unopposed estrogen on endometrium. 

Usual presentation - abnormal menstrual cycle with hyperandrogenism (hirsutism, acne, male-pattern alopecia), obesity, infertility.  Raised serum concentrations of LH, testosterone and androstenedione.

Treatment - fertility medication

References:

Middleton, WD, Kurtz, AB, Hertzberg, BS.  "Chapeter 23: Adnexa, Functioning and non-functioning ovarian cysts" Ultrasound: The Requisites, 2d ed.  2004:pp566-7.

Noel, P, Reinhold, C. "Polycystic Ovary Syndrome"  Accessed on 29 Jun 2013 at www.statdx.com at  https://my.statdx.com/STATdxMain.jsp?rc=false#dxContent;pcod_gyn.

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Additional Details:

Case Number: 65050973Last Updated: 2013-06-29
Anatomy: Genitourinary (GU)   Pathology: Metabolic
Modality: GU, USAccess Level: Readable by all users
Keywords: polycystic, PCOS

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