PCOS

Question 1

PCOS - background

Answer 1

1. PCOS is the most common endocrine disorder in women.
2. Responsible for 80% of all cases of anovulatory subfertility.
3. Estimated prevalence is 5–10% of women of childbearing age.
4. U/S evidence of polycystic ovaries is seen in 20–30% of women.
5. Abnormal HPO axis results from hyperinsulinaemia, which also stimulates an increase in GnRH and therefore an imbalance between LH and FSH -> derangement of E and P -> immature follicles -> no ovulation and oligomenorrhoea

Question 2

PCOS - etiology

Answer 2

1. Genetic (familial clustering).
2. Insulin resistance with compensatory hyperinsulinaemia (defect on
   insulin receptor).
3. Hyperandrogenism (elevated ovarian androgen secretion).
4. Obesity (esp, central):
   - BMI >30 in 35–60% of women with PCOS
   - Worsens insulin resistance

Leads to…
5. Derangement of HPO axis (?)

Question 3

PCOS - clinical features

Answer 3

1. Irregular menstrual cycles
2. Hirsutism
3. Acne
4. Obesity (often)
5. Infertility/subfertility

Question 4

PCOS - Rotterdam criteria for dx (3)

Answer 4

Requires the presence of two out of the following three variables and exclusion of other disorders:

1. Irregular or absent ovulations (cycle >42 days).
2. Clinical or biochemical signs of hyperandrogenism:
   - Acne
   - Hirsutism
   - Alopecia
3. Polycystic ovaries on pelvic USS: ≥ 12 antral follicles on one ovary, and/or increased ovarian volume (>10mL). Based on 2014 systematic review, a much higher threshold has been proposed (=/>25 follicles), but only if clinician uses transducer frequency that provides maximal resolution. This technology is not available to most clinicians, and it is suggested that the 2003 criteria (≥ 12 antral follicles/ovary) be used

Question 5

PCOS - ex

Answer 5

1. BMI
2. Signs of endocrinopathy
3. Hirsutis, alopecia
4. Acne
5. Acanthosis nigricans

Question 6

PCOS - ix`

Answer 6

1. Basal (day 2–5): LH, FSH, TFTs, prolactin, and testosterone.
   If hyperandrogenism:
2. Dehydroepiandrosterone sulphate (DHEAS), androstenedione
3. SHBG.
4. Exclude other causes of secondary amenorrhoea.
5. Pelvic USS.

Question 7

PCOS - long term health consequences

Answer 7

1. Obesity
2. Insulin resistance and metabolic abnormalities -> type II diabetes mellitus
3. GDM
4. Endometrial hyperplasia and endometrial carcinoma
5. Ischaemic heart disease (but long-term studies not proven)

Question 8

PCOS - mx

Answer 8

1. Lifestyle modification - Weight loss through diet and exercise
2. Improving menstrual regularity
   - Weight loss, COCP, metformin
3. Controlling symptoms of hyperandrogenism
   - Cosmetic (depilatory cream, electrolysis, shaving)
   - Antiandrogens (e.g. eflornithin facial cream or spironolactone) - can help with acne and hirsutism; can take 6-9mo to improve hair growth; avoid pregnancy (feminises a male fetus)
   - COCP - reduces serum androgen levels by increasing SHBG levles
4. Subfertility
   - Weight loss alone may achieve spontaneous ovulation
   - Clompihene (tx with the most evidence)
   - Can use gonadotrophins or metformin +/- clomiphene if clomiphene unsuitable or contraindicated
   - Laparoscopic ovarian drilling
   - IVF if ovulation cannot be achieved or does not succeed in pregnancy
   5.