Female and Male Reproductive Endocrinology

Question 1

Diagnostic criteria for PCOS

Answer 1

1. Oligo and/or anovulation
2. Clinical and/or biochemical hyperandrogenism
3. Polycystic ovaries

Exclusion of other causes: thyroid disorder, hyperprolactinaemia, Cushing’s syndrome, non-classic CAH, androgen secreting neoplasm

(Oligomenorrhoea = cycle >35 days, or <8 cycles a year)

Question 2

Causes of polycystic ovaries without diagnostic criteria for PCOS

Answer 2

1. Adolescents and young women (up to 70%)
2. Hypothalamic amenorrhoea, recovery from anorexia
3. Hyperprolactinaemia

Question 3

Causes of Hirsutism

Answer 3

Common:

• Idiopathic
• PCOS

Uncommon

• Drugs - danazol, OCP containing androgenic progesterones
• CAH
• Hyperthecosis
• Ovarian/adrenal tumours
• Severe insulin resistance syndromes
• Hyperprolactinaemia
• Cushing’s syndrome

Question 4

Biochemical evaluation in suspected PCOS

Answer 4

• Assays generally not validated for detection within the range for women
• Free serum testesterone, free androgen index
• SHBG low due to hyperinsulinaemia
• Androstenedione or DHEAS often mildly elevated
• Rule out: hyperprolactinaemia, thyroid disease, ovarian failure (raised FSH), hypothalamic amenorrhoea (low gonadotropin), pregnancy, non-classic CAH (morning 17 OHP), Cushing’s syndrome

Question 5

Pharmacological management of hirsutism

Answer 5

• COPC - suppresses ovarian androgen production, increases SHBG and reduces free androgens by 50%, response times can take 6-12/12
• Androgen blockade (in combination with COPC) - Spironolactone, cyproterone acetate
• Insulin sensitiser - metformin

Question 6

Pharmacological management of menstrual dysfunction in PCOS

Answer 6

• COCP
• Progestin only pill or Mirena - endometrial protection and contraception
• Cyclical progestin - aim 4 bleeds/year for endometrial protection

Question 7

Approach to ovulation induction in PCOS

Answer 7

• Lifestyle modification
• Letrozole (aromatase inhibitor)- 1st line in PCOS for anovulatory infertility
• Clomiphene - 80% ovulate, 50% conceive
• Metformin - controversial, appears valuable in increasing menstrual cycle and pregnancy rates
• Gonadotropin therapy
• IVF

Question 8

Conditions that decrease SHBG

Answer 8

• Obesity
• Nephrotic syndrome
• Hypothyroidism
• Use of glucocorticoids, progestins, androgenic steroids
• Diabetes

Question 9

Conditions that increase SHBG

Answer 9

• Aging
• Hepatic cirrhosis
• Hyperthydoidism
• Use of estrogens
• HIV
• Anorexia
• Pregnancy