PCOS

Question 1

what is the name of the criteria used to characterise PCOS?

Answer 1

• Rotterdam criteria
• oligo/ amenorrhoea (>35 days apart)
• USS shows large ovaries (>10cm) and/or multiple small follicles (12 or more in 10mm)
• clinical evidence of excess androgens (acne, hirsutism or biochemical evidence of raised testosterone)

Question 2

what is the main side effect?

Answer 2

• leading cause of infertility

Question 3

what is the aetiology?

Answer 3

• unknown, no gene or specific environmental substance identified
• insulin resistance, causes disordered LH production and excess ovarian androgen production
• increased androgens disrupt normal ovulatory cycle and folliculogenesis
• high BMI, high insulin, high androgens

Question 4

what should you focus on in the history?

Answer 4

• menstrual history
• previous pregnancies
• medications
• smoking, alcohol, diet
• identification of family members with diabetes and CVD

Question 5

what may be seen on physical exam?

what tests would you do?

Answer 5

• balding
• acne
• clitoromegaly
• male body hair distribution
• signs of insulin resistance: obesity, central fat distribution, acanthosis nigricans
• bimanual exam suggests enlarged ovaries
• Testosterone (>4.8nmol/l)
• pelvic sonogram

Question 6

what raised hormone is the hallmark of PCOS?Why does this happen?

Answer 6

• Elevated LH
• increased peripheral oestrogen production causes +ve feedback and increased GnRH secretion
• suppressed FSH levels result from increased peripheral oestrogen production and increased secretion of inhibin
• androgens converted by aromatisation which perpetuates chronic anovulation
• increased aromatisation in peripheral oestrogen tissue
• circulating testosterone increased because sex hormone binding levels decreased in PCOS

Question 7

What kind of clinical manifestations may this cause?

Answer 7

• menstrual irregularities (80%)
  including oligo/ amenorrhoea
• hirsutism (70%)
• obesity (50%)
• infertility (75%)
• acanthosis nigricans
• HAIR-AN syndrome (hyperandrogenism, insulin resistance and acanthosis nigricans)

Question 8

what is the long term sequelae of PCOS?

Answer 8

• endometrial hyperplasia/ adenocarcinoma
• insulin resistance/ type 2 diabetes (30% develop GDM, 50% T2 DM)
• diabetic problems
• risk of miscarriage or infertility

Question 9

management of PCOS?

Answer 9

• lower insulin levels (metformin) decrease androgen levels, improve ovulation rate and improve glucose tolerance
• oral contraceptives
• progestins (suppress FSH and LH and circulating androgens but breakthrough bleeding common)
• mirena coil to regulate menstruation
• clomiphene citrate (helps with fertility)

Question 10

what do oral contraceptives do in PCOS?

Answer 10

• decrease LH and FSH secretion and ovarian production of androgens
• increase hepatic production of SHBG (decreases androgens)
• decrease DHEA levels (precursor hormone)
• prevent endometrial neoplasia

Question 11

what is the surgical therapy for PCOS?

Answer 11

• ovarian drilling: includes ovulation (no greater effect than medical treatment)
• mechanical hair removal