Polycystic Ovary Syndrome (PCOS)

Definition & Epidemiology

Pathophysiology

1. Hypothalamic-Pituitary Dysregulation

• Increased LH pulse frequency and amplitude, leading to a raised LH:FSH ratio (in ~⅔ of patients)
• Excess LH stimulates ovarian theca cells → excess androgen production
• Insufficient FSH → arrested follicular development → anovulation

2. Hyperandrogenism

• Elevated androgens (testosterone, androstenedione, DHEAS) arise from both the ovaries and adrenal glands
• Androgens are converted peripherally (especially in adipose tissue) to estrogens, which exerts positive feedback on LH — creating a self-perpetuating cycle
• Skin 5α-reductase converts testosterone → DHT, causing hirsutism and acne (activity varies by ethnicity, explaining why hirsutism appears in ~70% of US patients vs. only 10–20% in Japan)

3. Insulin Resistance & Hyperinsulinemia

• Present in the majority, independent of obesity
• Hyperinsulinemia directly stimulates ovarian androgen production and suppresses sex hormone-binding globulin (SHBG), increasing free androgen levels
• PCOS typically arises at puberty; obesity worsens the phenotype by amplifying hyperinsulinemia

Clinical Features

Diagnosis

1. Oligo-ovulation or anovulation
2. Clinical and/or biochemical hyperandrogenism (hirsutism, acne, alopecia; or elevated free testosterone)
3. Polycystic ovarian morphology on ultrasound — ≥20 follicles (2–9 mm) in either ovary and/or ovarian volume >10 mL

In adolescents, diagnosis requires both persistent anovulation and clinical/biochemical HA (PCO morphology alone is insufficient).

Differential Diagnoses to Exclude:

• Non-classic congenital adrenal hyperplasia → 17-OHP (follicular phase) to screen
• Cushing syndrome → 24-hr urinary cortisol / overnight dexamethasone suppression
• Hyperprolactinemia → serum prolactin
• Androgen-secreting neoplasm → imaging if testosterone very high
• Thyroid disease → TSH

Ancillary Workup at Diagnosis:

• Fasting glucose / oral GTT (screen for impaired glucose tolerance/T2DM)
• Fasting lipid profile (overweight/obese women)
• BMI, waist circumference, blood pressure
• PHQ-2 (depression screen)
• Consider endometrial biopsy if prolonged anovulation (endometrial hyperplasia risk)

Management

All Patients — Universal

• Lifestyle modification (diet + exercise): first-line for all women; even modest weight loss (5–10%) improves menstrual regularity, hyperandrogenism, and insulin sensitivity
• Screen and monitor: obesity, hypertension, glycemic control, depression, anxiety — at diagnosis and at regular intervals

Women Not Seeking Pregnancy

Women Seeking Pregnancy (Ovulation Induction)

1. Letrozole (aromatase inhibitor) — first-line for ovulation induction in PCOS
2. Clomiphene citrate ± metformin — second-line
3. Injectable gonadotropins — used judiciously (risk of ovarian hyperstimulation syndrome is higher in PCOS)
4. Metformin — adjunct with diet/exercise in obese women; alone is not recommended for infertility treatment

Metformin is not recommended as monotherapy for endometrial protection, treatment of hyperandrogenic symptoms, prevention of pregnancy loss, or prevention of gestational diabetes.

Complications & Long-term Risks

Reproductive

• Anovulatory infertility — most common endocrine cause
• Increased risk of early miscarriage, gestational diabetes, gestational hypertension, preeclampsia, preterm birth
• Prepregnancy counseling and lifestyle management recommended before conception

Metabolic / Cardiovascular

• Type 2 diabetes and impaired glucose tolerance — screen with oral GTT
• Dyslipidemia (elevated LDL, triglycerides; low HDL) → increased long-term cardiovascular disease risk
• Obstructive sleep apnea — increased prevalence, refer if suspected
• Non-alcoholic fatty liver disease

Oncological

• Endometrial carcinoma — chronic anovulation leads to unopposed estrogen stimulation; endometrial biopsy if at increased risk

Psychiatric

• Higher rates of depression and anxiety — screen at diagnosis and regularly

Recent Evidence (2024–2025)

• Inositol (myo-inositol + D-chiro-inositol) was evaluated in a 2024 meta-analysis for the 2023 updated PCOS guidelines — modest evidence for improving metabolic and reproductive outcomes (PMID: 38163998)
• Lifestyle interventions remain foundational: a 2025 systematic review confirmed significant improvements in insulin resistance, androgen levels, and menstrual regularity with structured exercise and diet (PMID: 39861440)
• Pregnancy outcomes: A 2024 meta-analysis in Nature Communications quantified increased risks of gestational diabetes, preeclampsia, and preterm birth, reinforcing preconception counseling (PMID: 38965226)

Inguinal Hernia

Definition & Epidemiology

Relevant Anatomy

• Floor: inguinal ligament
• Roof: internal oblique and transversus abdominis muscles
• Anterior wall: external oblique aponeurosis
• Posterior wall: transversalis fascia

• Medially: rectus abdominis
• Laterally: inferior epigastric vessels
• Inferiorly: inguinal ligament

Classification

Special Hernia Variants

• Richter hernia: only the antimesenteric border of intestine herniates (partial wall circumference) → may strangulate without overt bowel obstruction; no vomiting
• Reduction en masse: hernia reduced manually but bowel remains strangulated inside the peritoneal cavity within the sac — a dangerous, rare complication of ED reduction

Pathogenesis

Indirect (Congenital/Pediatric)

• Failure of closure of the processus vaginalis — a peritoneal diverticulum that follows the testis as it descends into the scrotum
• All pediatric inguinal hernias are by definition indirect
• Partial closure → hydrocele; complete patency → hernia
• High incidence in premature infants (closure normally occurs before birth)

Direct (Acquired/Adult)

• Acquired weakness of the transversalis fascia (posterior inguinal wall)
• Associated with increased intra-abdominal pressure (chronic cough, constipation, heavy lifting), connective tissue disorders, and aging

Clinical Presentation

• Groin bulge — most common; appears on standing/Valsalva, reduces with recumbency
• Aching or dragging sensation in the groin, worsened by exertion
• Scrotal swelling — in large indirect hernias extending into the scrotum
• On exam: thickened spermatic cord on the affected side; impulse felt on cough at the external ring

Complications

Diagnosis

• Ultrasound: operator-dependent; identifies hernia sac, contents, reducibility; free fluid in sac = sensitive for incarceration/strangulation; best for children and pregnant women (no radiation)
  • Doppler US: insensitive for venous/lymphatic compromise; can detect arterial flow
• CT scan: best overall imaging modality — identifies uncommon types (Spigelian, obturator), confirms incarceration/strangulation, demonstrates bowel obstruction
• Plain films: non-diagnostic for hernia; may show bowel obstruction
• Herniography (peritoneography): fluoroscopic contrast exam — reserved for occult hernias when other imaging is inconclusive; sensitive with high negative predictive value

Management

Adults — Elective Repair Indications

• Symptomatic hernia → elective repair
• Femoral hernia → repair recommended regardless of symptoms due to very high strangulation risk (22% at 3 months, 45% at 21 months)
• Asymptomatic inguinal hernia in elderly/high-risk patients → watchful waiting may be considered

Surgical Repair Options

Open Approach

• Lichtenstein tension-free mesh repair — gold standard for open repair; prosthetic mesh placed over the inguinal floor; low recurrence (~1%)
• Herniorrhaphy (children) — high ligation of hernia sac only; no floor reconstruction needed
• Mesh plug repair — alternative open method; higher recurrence for inguinal, acceptable for femoral

Laparoscopic Approach

• TEP (Total ExtraPeritoneal) — mesh placed extraperitoneally; avoids peritoneal entry
• TAPP (TransAbdominal PrePeritoneal) — transabdominal, mesh placed preperitoneally
• European Hernia Society recommends Lichtenstein or TEP as the standard approaches; comparable outcomes but laparoscopic has less postoperative pain and earlier return to work
• Preferred when: bilateral hernias, recurrent hernias, unclear femoral vs. inguinal type, or prior lower abdominal surgery makes anatomy clearer laparoscopically

Anesthesia

• All repairs can be performed under local, spinal, epidural, or general anesthesia
• Laparoscopic repairs require general anesthesia
• In premature infants: spinal anesthesia preferred to reduce postoperative apnea risk vs. general anesthesia

ED Management of Incarcerated Hernia

1. NPO status
2. Adequate IV narcotic analgesia
3. Apply cold packs to reduce swelling
4. Manual reduction: grasp and elongate the hernia neck with one hand; apply firm steady pressure to the proximal hernia at the neck with the other hand (NOT the distal end — pushing distally causes ballooning at the neck)
5. After successful reduction: observe for serial abdominal exams; watch for reduction en masse
6. Failed reduction or any sign of strangulation → immediate surgery; IV antibiotics + fluid resuscitation + surgical consult

Strangulated Hernia

• IV broad-spectrum antibiotics
• Fluid resuscitation
• Urgent/emergency surgical repair
• May require bowel resection

Pediatric Considerations

• Male:female ratio 10:1; right > left (right testis descends later)
• Spontaneous resolution does not occur → all confirmed pediatric inguinal hernias require surgical repair
• Premature infants at highest risk for incarceration due to narrow inguinal ring
• Usually performed as open herniorrhaphy (high ligation of sac); no floor repair needed
• Laparoscopic approach increasingly adopted (<2 years) — also allows simultaneous inspection of contralateral side
• Contralateral exploration: ~30% have patent processus vaginalis on the opposite side; options include laparoscopic inspection at time of repair
• Recurrence <1% in children (vs. ~1–5% in adults with mesh repair)

Complications of Surgical Repair

• Recurrence: ~1% with Lichtenstein mesh; higher with tissue repair
• Chronic groin pain (neuropathic): injury to ilioinguinal, iliohypogastric, or genitofemoral nerves
• Wound infection
• Seroma/hematoma
• Testicular atrophy: injury to testicular artery or vas deferens
• Mesh complications: infection, migration, erosion
• Overall complication rate: up to 20%