PCOS

Question 1

long term complications of PCOS

Answer 1

1. Subfertility
2. Diabetes mellitus
3. Stroke & transient ischaemic attack
4. Coronary artery disease
5. Obstructive sleep apnoea
6. Endometrial cancer

Question 2

definition of PCOS

Answer 2

1. Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age.
2. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome

3.

Question 3

features of PCOS

Answer 3

1. subfertility and infertility
2. menstrual disturbances: oligomenorrhea and amenorrhoea
3. hirsutism, acne (due to hyperandrogenism)
   obesity
4. acanthosis nigricans (due to insulin resistance)

Question 4

investigations for PCOS

Answer 4

1. Pelvic ultrasound: multiple cysts on the ovaries
   FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis.
2. Prolactin may be normal or mildly elevated.
3. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
   check for impaired glucose tolerance

Question 5

aietiology + pathophys of PCOS

Answer 5

• The aetiology of polycystic ovary syndrome is poorly understood, and is thought to be multifactorial in origin.
• The two most common hormonal abnormalities present in PCOS are:

1. Excess luteinising hormone (LH) – produced by the anterior pituitary gland in response to an increased GnRH pulse frequency.
   - This stimulates ovarian production of androgens.
   Insulin resistance – resulting in high levels of insulin secretion.
   - This suppresses hepatic production of sex hormone binding globulin (SHBG), resulting in higher levels of free circulating androgens.

• Despite the high levels of LH, the increased circulating androgens suppress the LH surge (which is required for ovulation to occur).
• Follicles develop within the ovary, but are arrested at an early stage (due to the disturbed ovarian function) – and they remain visible as “cysts” within the ovary.

Question 6

risk factors for pcos

Answer 6

Individuals with diabetes, irregular menstruation and/or a family history of PCOS are at an increased risk of developing polycystic ovary syndrome.

Question 7

differential diagnosis

Answer 7

1. Hypothyroidism – obesity, hair loss and insulin resistance.
2. Hyperprolactinaemia – oligomenorhoea/amenorrhoea, acne and hirsutism.
3. Cushing’s disease – obesity, acne, hypertension, insulin resistance and depression.

Question 8

investigations

Answer 8

In the UK, the most commonly used diagnostic criteria is the Rotterdam Criteria (2003). It gives a diagnosis of PCOS if two out of three criteria are met:

1. Oligo- and/or anovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovaries on imaging - ultrasound finds many ovarian cysts

Question 9

blood test results in PCOS

Answer 9

1. testosterone - raised
2. SHBG - low
3. LH - raised
4. FSH - normal
5. Progesterone - low

Question 10

management of PCOS - Annovulation + Amenorrhea

Answer 10

1. Annovulation + Amenorrhea
   - An anovulatory menstrual cycles, the effect of oestrogen is unopposed due to lower levels of progesterone.
   - This can cause endometrial hyperplasia, which has a risk of becoming malignant.
   - Therefore, in amenorrhoeic women, it is important to protect the endometrium from hyperplasia by inducing at least 3 bleeds per year. This can be done by using:

• *Combined oral contraceptive pill (low dose).
• *Dydrogesterone – a progesterone analogue. This is often used if the combined pill is contraindicated.

Question 11

management of PCOS - Obesity

Answer 11

Weight management in PCOS is vital – achieving a BMI of under 30 may be enough to trigger a regular menstrual cycle.

Advise and encourage a heathy lifestyle, including healthy diet and exercise. This will increase insulin sensitivity. In severe cases, orlistat (pancreatic lipase inhibitor) can be prescribed.

Question 12

management of PCOS - infertility

Answer 12

1. Clomifene +/- metformin helps induce ovulation and is therefore the first line of treatment for women wishing to conceive. However, there is an increased risk of multiple pregnancies, ovarian hyperstimulation syndrome and ovarian cancer (therefore it is limited to use in 6 cycles).

Women with a normal BMI could also benefit from laparoscopic ovarian drilling.

Note: As well as improving insulin sensitivity, Metformin helps with menstrual disturbance and ovulatory function. NICE guidelines recommend Metformin for women trying to conceive with a BMI >25.

Question 13

management of PCOS - Hirsutism

Answer 13

1. Hirsutism can be treated both cosmetically and/or with anti-androgen medication such as cyproterone, spironolactone or finasteride. However, these should be avoided during pregnancy as they are teratogenic.
2. Eflornithine is a topical cream that can also be used to help reduce the growth rate of facial hair.