Gynaecology Flashcards
What drug is used before myomectomy?
Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery which helps to reduce the size of the fibroids.
Who are the common target groups for uterine fibroids?
- Nulliparity
- Early menarche (< 10 years old)
- Age: 25–45 years
Fibroids are largely found in women of reproductive age
influenced by hormones (i.e., estrogen, growth hormone, and progesterone)
During menopause, hormone levels begin to decrease and leiomyomas begin to shrink - Increase incidence in African Americans - V.V. imp
- Obesity
- Family history
What are the typical symptoms of fibroids?
- may be asymptomatic - depending on the size, number and location
- Abnormal menstruation - menorrhagia and dysmenorrhea- increased total surface area as a result of the bulging uterine wall, impaired uterine wall contractility, or micro/macrovascular abnormalities.
- Features of mass effect:
i. Back or pelvic pain: cramping pains, often during menstruation
ii. urinary symptoms, e.g. frequency, may occur with larger fibroids and bowel symptoms (bloating, constipation) - Reproductive abnormality - Infertility and Dyspareunia (obstructed uterine cavity and/or impaired contractility of the uterus)
How are fibroids diagnosed?
Transvaginal US
What is the crude pathophysiology of fibroids?
Oestrogen-dependent benign tumours
What are the complications of fibroids during pregnancy?
Pain (red degeneration) -haemorrhage into tumour - commonly occurs during pregnancy
Premature labour
Malpresentation
Obstructed labour (cervical uterine fibroid)
Difficulty for CS (C-section)
What is primary Amenorrhoea? and what are the possible causes?
failure to start menses by the age of 16 years
- Turner’s syndrome
- testicular feminisation
- congenital adrenal hyperplasia
- congenital malformations of the genital tract
What is secondary Amenorrhoea? and what are the possible causes?
cessation of established, regular menstruation for 6 months or longer
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis*
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
What is oligomenorrhoea?
Menstruation occurs every 35days -6mths
What is hypothalamic hypogonadism? What are the hormone findings expected to be?
It is a cause of secondary amenorrhoea. It is caused due to psychological factors, low weight, anorexia nervosa and excessive exercise (atheletes).
GnRH, FSH , LH and oestradiol are all reduced.
(Bone density is reduced to low oestrogen)
What other gynaecological tests are required to rule out abdo pain in women?
In addition to routine diagnostic work up of abdominal pain, all female patients should also undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.
What are the features of mittelschmerz?
Usually mid cycle pain. (recurrent unilateral pain) Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours.
What type of ovarian cysts immediately require biopsy?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy
What is the commonest type of ovarian cyst seen in young women?
Follicular cysts - commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles
Functional cysts associated with hyperestrogenism and endometrial hyperplasia
Which ovarian cyst is more likely to be associated with intraperioteneal bleeding?
Corpus leuteal cyst - Unreleased corpus luteum may fill with blood or fluid and form a corpus luteal cyst
Functional cysts - Produces progesterone, which may delay menses
Associated with progesterone-only contraceptive pills and ovulation-inducing medication
What the broad types of ovarian cysts and give examples
Functional - Follicular cysts, Corpus leuteal cysts, Theca Leutin cyst
Non-functional - Benign germ cell tumours (Dermoid cysts), Benign epithelial tumours ( Serous cystadenoma, Mucinous cystadenoma)
What is the most common benign germ-cell ovarian tumour in woman under the age of 30 years
Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
What is the most common benign epithelial ovarian tumour?
Serous cystadenoma- the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
What are 6 gynaecological Differentials for abdo pain in females?
- Ovarian Torsion
- Ruptured ovarian cyst
- Endometriosis
- Ectopic pregnancy
- Mittelschmerz
- PID
How to differentiate ovarian torsion from ruptured ovarian cyst?
Ruptured ovarian cyst presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.
Ovarian or adnexal torsion can present similarly with sharp unilateral pain often associated with nausea and vomiting. There is a tender palpable adnexal mass on bimanual exam. Ultrasound shows an enlarged, oedematous ovary with impaired blood flow.
How is the risk stratification performed for ovarian cycts and tumours
RMI - Risk of malignancy index
U x M x CA125
o U = Ultrasound score (0/1/3)
o M = Menopausal status (1/3)
o CA125 = Serum cancer antigen 125 level (U/L)
RMI <25 - Low risk
RMI 25-250 - Moderate risk
RMI >250 - High risk
What is the management of ovarian cysts in premenopausal women?
In a premenopausal woman, cyst of <5cm should NOT cause concern unless:
o Other suspicious features
o /Patient is symptomatic (eg: pain)
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Consider laparoscopic cystectomy:
o Avoid spillage of contents (in all >5cm cysts & dermoid cysts)
o Can be done by removing cyst in an ‘endobag’
What is the follow up of ovarian cysts in premenopausal women if cyst is persistent after conservative theraphy and waiting
• Rescan in 6wks to see if the cyst has resolved:
o If cyst is persistent then monitor with:
USS
/CA125
What is the management of ovarian cysts in postmenopausal women?
By definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst
**Regardless of nature or size should be referred to gynaecology for assessment
Treatment include Bilateral laprosocopic oophorectomy or in high RMI cases - full staging laprotomy
What is the most sinister diagnosis to suspect when fairly young patient presents with amenorrhoea and pain?
Ectopic pregnancy
What is the commonest site of ectopic preganancy and which is the most dangerous?
- Most common in ampulla
* Most dangerous (highest risk to rupture) = isthmus
What causes rupture of the ovarian cysts?
increase in intracystic pressure or intra-abdominal pressure
Vigorous physical activity
Vaginal intercourse
Large cysts
Reproductive age
What are the most common gynae causes of sudden onset lower abdo pain?
ovarian torsion
ovarian cyst rupture
What are the risk factors of ectopic pregnancy?
Anything slowing the ovum’s passage to the uterus
Anatomic alteration of the fallopian tubes is the main cause of ectopic pregnancy
- A history of PID
- Previous ectopic pregnancy
- Past surgeries involving the fallopian tubes (damage to tubes (pelvic inflammatory disease, surgery)
- Endometriosis
- Bicornate uterus
Non‑anatomical risk factors
1. Intrauterine device (IUD) - Pregnancies that occur despite IUD contraception tend to attach more frequently outside of the uterus
- History of infertility -Infertility is often caused by tubal abnormalities, which also increase the risk of ectopic pregnancy.
- Hormone therapy - Hormone therapy may cause hormonal dysregulations, which are thought to slow down the transport of fertilized eggs
- IVF
- Progestrone only pill
What is the typical history seen with ectopic preganancy?
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
What are the typical clinical features in ectopic pregancy?
!Often asymptomatic (Unsure dates)!
Others patients usually present with signs and symptoms 4–6 weeks after their last menstrual period.:
1. Typcially Amenorrhoea of 6-8 weeks. if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
- Lower abdominal pain and guarding (often mild, constant and unilateral) - mostly if ruptured or due to tubal spasm;
typically the first symptom - Vaginal bleeding - often confused as delayed menstruation, usually small amount and often brown
- Signs of pregnancy- amenorrhea, nausea, breast tenderness, frequent urination
- Peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination (haemoperitoneium)
What are the signs observed in ectopic preganancy?
Often have no specific signs
o Uterus usually normal size
o Cervical excitation, cervical motion tenderness
o Adnexal tenderness
o Adnexal masses – Very rarely
o Peritonism: Due to intra-abdominal blood if ectopic ruptured
What are the DDx to consider if cervical excitation is positive?
Ectopic pregnancy
Pelvic inflammatory disease
Positive sign can also exclude appendicitis
What are the features than can be used to differentiate ectopic pregnancy from PID
Ectopic - Lower unilateral abdominal pain and guarding with findings of amenorrhoea, positive pregnancy test and echogenic mass on US
PID - bilateral lower abdominal pain and fever, menorrhagia and metrorrhagia (IMB), dyspareunia, purulent cervical discharge§
Differentiating features between ectopic pregnancy and ruptured ovarian cyst
Ectopic - Lower unilateral abdominal pain and guarding with findings of amenorrhoea, positive pregnancy test and echogenic mass on US
Ruptured cyst - Sudden onset of unilateral abdominal pain, Onset usually during physical activity (exercise, sexual intercourse)
What is the best test to diagnose ectopic pregnancy?
TVS - to locate the pregnancy
Supportive Findings:
- Adnexal mass - most common finding
- Free fluid - strongly indicating the presence of haemoperitoneum - however non-specific
- Empty uterine cavity in combination with a thickened endometrial lining
What is the test used to check for failing pregnancy and what are the threshold values?
Serum progesterone
If <20nmol/L = Highly suggestive of failing pregnancy in both:
Ectopic pregnancy
Intrauterine pregnancy (IUP)
What is the blood test used to check for pregnancy
Serum β-hCG level
What is the discriminatory level for a single Serum β-hCG level to observe IUP with TVS
Cutoff is typically β-hCG > 1,500–2,000 IU/L
Inability to visualize pregnancy on ultrasound at the discriminatory level strongly suggests ectopic pregnancy.
Multiple pregnancies may have higher β-hCG levels (In multiple pregnancies, the β-hCG discriminatory level may be reached before the pregnancy can be visualized.)
How do you suspect ectopic from one serum β-hCG?
Inability to visualize pregnancy on ultrasound at the discriminatory level (> 1,500–2,000 IU/L) strongly suggests ectopic pregnancy.
How often do you perform a serial serum β-hCG?
48hrs after the admission
What do you expect to see in the serial serum β-hCG for a normal IUP?
Intrauterine pregnancies: β-hCG increases by ≥ 66%
Suboptimal rise is suspicious
What do you expect to see in the serial serum β-hCG for an ectopic pregancy?
An insufficient increase or decrease of β-hCG. (<66%)
What do you expect to see in the serial serum β-hCG for a spontaneous abortion?
patients have a decrease of β-hCG ≥ 35%
A decrease < 35% should raise concern for either ectopic pregnancy or spontaneous abortion.
What is the gold standard diagnostic test for ectopic but should only be done if clinically necessary?
Exploratory laproscopy - Unstable patients suspected of having an ectopic pregnancy
In pregnancy of unknown location if the location is still uncertain after 7–10 days
What is the criteria for patients applicable for expectant management in ectopic pregnancy?
- Unruptured
- Size <35mm / 3cm
- Asymptomatic
- No foetal heartbeat
- serum B-hCG <1000IU/L and declining
- Compatible if another intrauterine pregnancy
What does expectant management involve in ectopic pregnancy?
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
To monitor serum hCG:
- Initial serum hCG
- Repeat every 48h until repeated fall in level
- Then weekly until <15IU
***No level of hCG at which rupture can’t occur!!! (Even when it’s falling) – So monitor the S&S rather than just blood tests and scans!!!
What is the criteria for patients applicable for medical management in ectopic pregnancy?
- Unruptured
- Size <35mm / 3.5cm
- No pain
- No foetal heartbeat
- serum B-hCG <1500IU/L
- Not Compatible if another intrauterine pregnancy
What does medical management involve in ectopic pregnancy?
Methotrexate IM
o 1 dose of 50mg/m2
hCG level:
Measured at 4 & 7d
If the ↓ of hCG btwn 4 & 7d <15%: (up to 25% of cases)- Give 2nd dose of methotrexate
What are the SEs of methotrexate?
o Conjunctivitis
o Stomatitis
o GI upset
o Abdominal pain (difficult to differentiate from a rupturing ectopic)
After treatment, use reliable contraception for 3mths (because methotrexate is teratogenic)
What are the contraindication for using methotrexate
Breastfeeding Methotrexate sensitivity Immunodeficiency Peptic ulcer disease Ruptured ectopic pregnancy Pulmonary diseases - severe asthma Low creatinine clearance Alchohol use disorder, chronic liver disease
How does methotrexate function
inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.
What is the criteria for patients applicable for surgical management in ectopic pregnancy?
- Can be ruptured
- Size > 35mm / 3.5cm
- Severe pain
- Visible foetal heartbeat
- serum B-hCG >1500IU/L
- Compatible if another intrauterine pregnancy
What does surgical management involve in ectopic?
- Salpingostomy/ Salpingotomy (tube‑conserving operation) - Create an opening into the tube to remove EP BUT do not remove the tube
- Salpingectomy - removal of the tube
How do you chose salpingotomy vs salpingectomy
If the contralateral tube is healthy, salpingectomy over salpingotomy.
Salpingotomy is the primary treatment if the other tube is not healthy to preserve chance of future ectopic pregnancy.
Women with salpingotomy should be followed up with serum hCG to detect and treat persistent trophoblast early.
What is the definition of recurrent miscarriage?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
What are the some causes of recurrent miscarriages?
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. 3. Polycystic ovarian syndrome
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
What is the histological change in cervical ectropion?
the squamous cell epithelium of the ectocervix is replaced by columnar cell epithelium of the endocervix
What causes the cervical ectropion?
physiological influence of estrogen (e.g., puberty, pregnancy, certain oral contraceptives)
What are the features of cervical ectropion?
- vaginal discharge
- post-coital bleeding
- red ring around the os
What is the treatment for cervical ectropion?
stop hormonal contraception
cautery with diathermy as an outpatient if the women wishes
What are the causes of primary amenorrhoea?
- Constitutional delay i.e. a late bloomer, has secondary sexual characteristics
- Anatomical i.e. mullerian agenesis (patient develops secondary sexual characteristics and has variable absence of female sexual organs)
- Imperforate hymen (characterised by cyclical pain and the classic bluish bulging membrane on physical examination)
- Transverse vaginal septae (characterised by cyclical pain and retrograde menstruation)
- Turner syndrome (XO chromosome)
- Testicular feminisation syndrome (XY genotype, no internal female organs)
- Kallmann syndrome (failure to secrete GNRH)
- congenital adrenal hyperplasia
what are the causes of secondary amenorrhoea?
- Pregnancy
- Patient is using contraception
- Menopause
- Lactational amenorrhoea
- Hypothalamic amenorrhoea (suppression of GnRH due to stress, excessive exercise, eating disorder)
- Endocrinological (hyperthyroidism, polycystic ovary disease, Cushing’s syndrome, hyperprolactinaemia, hypopituitarism)
- Premature ovarian failure (autoimmune, chemotherapy, radiation therapy)
- Asherman’s syndrome (iatrogenic intrauterine adhesions/cervical stenosis)
- Sheehan syndrome
What are the investigations required for amenorrhoea?
- Exclude pregnancy with urinary or serum bHCG
- Gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- Prolactin
- Androgen levels: raised levels may be seen in PCOS
- Oestradiol
- Thyroid function tests
What are the causes of delayed puberty with short stature?
Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome
What are the causes of delayed puberty with normal stature?
Polycystic ovarian syndrome
Androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome
What is the triad of features in hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
When does hyperemesis gravidarum mostly present?
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks
What are the common associations of hyperemesis gravidarum?
- Multiple pregnancies
- Trophoblastic disease - Molar pregancy
(Both cause increased hCG) - Hyperthyroidism (Thyroid resembles hCG)
- Nulliparity
- Obesity
True or false: smoking exacerbates hyperemesis gravidarum
Smoking is associated with a decreased incidence of hyperemesis.
What is the referral criteria for nausea and vomiting?
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
A lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.
What investigations do you perform for suspected hyperemesis gravidarum?
- Urinalysis: Ketones (As body switches to ketogenesis as lack of glucose from N&V)
- MSU – To exclude UTI
- FBC - increased haematocrit
- U&E -
↓K+ ↑Na+ (body try to reabsorb water thru Na+ reabsorption)
Metabolic hypochloraemic alkalosis (Losing H+ thru vomiting) - LFT - Increased transaminases, reduced albumin
- USS - to exclude multiple and molar pregnancies
What are the complications of hyperemesis gravidarum?
- Thiamine deficiency - Wernicke’s encephalopathy
- Mallory-Weiss tear
- Hyponatraemia - rapid reversal may lead to central pontine myelinolysis
- acute tubular necrosis
- fetal: small for gestational age, pre-term birth
How do you grade the severity of Nausea and vomiting in pregnancy?
Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
What is the 1st line management in hyperemesis gravidarum?
Fluids - NaCL or Hartmann’s
• Avoid glucose-containing fluids as they can precipitate Wernicke’s encephalopathy
For the conversion of pyruvate to enter Krebs cycle (requires Thiamine!!!):
So if giving glucose-containing fluids without Thiamine first = Produce more lactate!!!
What is 2nd line in hyperemesis gravidarum management after fluids
If no response to IV fluid & electrolyte replacement; then consider:
- antihistamines such as Promethazine OR Cyclizine
- Procholarpezine +/- Metaclopramide
- Ondensetron/Granisetron
What are some S&S of hyperemesis gravidarum?
o Muscle wasting o Ptyalism (inability to swallow saliva) o Inability to keep food/fluid down o Hypovolaemia o Behaviour disorder o Haematemesis (Mallory-Weiss tears)
What type of ovarian cyst ruptures and may cause pseudomyxoma peritonei
Mucinous cystadenoma
A 32-year-old female presents with lower abdominal pain. She is 8 weeks pregnant. A simple ovarian cyst is evident on transvaginal ultrasound. An 8-week intrauterine pregnancy is also confirmed. What is the most appropriate management of the cyst?
Reassure the patient that it is normal and leave the cyst alone
In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards. Reassurance is important in the above situation as maternal anxiety is likely to be high. Anxiety in pregnancy should be avoided wherever possible in order to avoid adverse outcomes to both mother and foetus.
What are the types of cervical cancer?
squamous cell cancer (80%)
adenocarcinoma (20%)
What is the peak incidence in cervical cancer?
Dual peak in incidence:
o 30-39yo
o Over 70s
What is the most common causative factor for cervical cancer?
Most due to persistent infection with high risk HPV subtypes; mainly:
o HPV 16
o HPV 18
HPV 33
Untreated high grade CIN leads to cervical cancer in 20-30% of women over 10yrs
What are the risk factors for cervical cancer?
- Early onset of sexual activity; multiple sexual partners (strongest risk factors)
- High parity
- Immunosuppression (e.g., HIV infection, transplant patients)
- History of sexually transmitted infections (e.g., herpes simplex, chlamydia)
- Cigarette smoking and/or exposure to second-hand smoke (for squamous cell cancer types only)
- Oral contraceptives
- Low socioeconomic status
What is the mechanism by which HPV causes cervical cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
What are the features of cervical cancer?
PCB Cervical smear showing invasion? Incidental finding on treatment of CIN Post-menopausal bleeding: <1% of PMB women have cervical cancer Watery vaginal discharge
What are the signs of advanced disease in cervical cancer
o Heavy bleeding PV o Ureteric obstruction o Weight loss o Bowel disturbance o Fistula (Vesicovaginal = Most common)
What type of ovarian cyst is most likely to cause pseudomyxoma peritonei
Mucinous cystadenoma
What is the diagnosis in post menopausal bleeding until and proven otherwise?
endometrial cancer
What is the diagnosis of exclusion in post-menopausal bleeding?
Atrophic vaginitis is a diagnosis of exclusion. Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS. While this is most likely atrophic vaginitis, it still must be investigated to rule this out. Once a TVUS is done, if it comes back normal then either discharge with cream or referral to HRT clinic would be the most appropriate, but TVUS must be done first. If it is abnormal (>4mm), then endometrial biopsy would be done. Laparoscopy would not help.
What are the features of atrophic vaginitis?
Vaginal soreness, dryness
Dyspareunia, burning sensation after sex
Discharge, occasional spottin
Decreasing labial fat pad
On examination, the vagina may appear pale and dry.
What is the management of atrophic vaginitis?
vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
What is the first line treatment for stress incontinence? What is the medical mx?
Pelvic floor muscle training (8 contractions 3 times per day for 3mths)
• Duloxetine = ONLY drug to treat moderate to severe SUI (BUT NOT RECOMMENDED BY NICE)
What is the first line treatment for urge incontinence?
Bladder retraining for >6 weeks (To gradually increase intervals between voiding)
What are the risk factors of urinary incontinence in women?
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
What are the types of urinary incontinence in women?
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
What are the investigations done for urinary incontinence/
- Bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
What is the pathophysiology fo PCOS
- Reduced insulin sensitivity (peripheral insulin resistance) is present in PCOS, as in metabolic syndrome → hyperinsulinemia
- Hyperinsulinaemia increases GnRH pulse frequency
- Raised LH:FSH
- Leading to: (Insulin acts on ovary & adrenal) Increased ovarian androgen production and Reduced follicular maturation
Increased androgen production in ovarian theca cells → not getting converted to oestrogen because of the low stimualtion of the granulosa cell by FSH
- As patient becomes obese (due to insulin resistance)
- More adipose tissue available:
Adipose tissue has aromatase; convert:
Androstenedione –> oestrone
Testosterone –>oestradiol - Inhibits the production of SHBG (sex hormone-binding globulin) in the liver → ↑ free androgens and estrogens
!!!!!Thus PCOS = ↑ Androgen + ↑ Oestrogen!!! (&normal FSH, high LH)
What are the characteristic features of PCOS?
- Menstrual irregularities (primary or secondary amenorrhea, oligomenorrhea)
- Subfertility or infertility
- Obesity and signs of metabolic syndrome (DM2, HTN, CVD, Dyslipidaemia)
- Hirsuitism
- Androgenic alopecia
- Acne vulgaris and oily skin
- Acanthosis nigrican - hyperpigmented, velvety plaques - axilla and neck (Elevated levels of insulin stimulate keratinocyte and dermal fibroblast proliferation via interaction with insulin-like growth factor 1.)
How is PCOS diagnosed?
Rotterdam criteria for diagnosing PCOS
Presence of 2 out of the 3 following variable:
1. Oligo/Anovulation - cycle >42 days
2. Clinical/ biochemical signs of hyperandrogenism - acne, hirsutism or alopecia
3. Polycystic ovaries on pelvic USS > 12 antral follicles on 1 ovary and ovarian volume> 10ml
need to exclude other causes of irregular cycles before the diagnosis is made
What are the investigations required for PCOS?
- pelvic ultrasound: multiple cysts on the ovaries - strong of pearls appearance
- 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.
- Prolactin may be normal or mildly elevated.
- Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes (Both free and total)
- check for impaired glucose tolerance
What are the differentials for virlization and menstrual changes?
Congenital adrenal hyperplasia
Cushings disease (ACTH can stimulate the
PCOS
Thyroid disorders
hyperprolactinaemia
androgen secreting tumour
What are the long term consequences of PCOS?
- PCOS increase risk factors for ischaemic heart disease
- Pregnant women with PCOS: Increased risk of gestational diabetes
- Long periods of 2o amenorrhoea leads to unopposed oestrogen (raised due to more adipose tissue); risk factor of: endometerial hyperplasia and endometrial carcinoma
What is the management of PCOS patient
Weight loss - in order to increase insulin sensitivity .
Smoking cessation
If treatment for infertility is not sought: therapy aimed at controlling menstrual, metabolic, and hormonal irregularities
If the patient is overweight (BMI ≥ 25 kg/m2)
First-line: weight loss via lifestyle changes (e.g., dietary modifications, exercise)
Second-line (as an adjunct): combined oral contraceptive therapy - co-cyprindiol
If the patient is not overweight: combined oral contraceptive therapy
If seeking treatment for infertility:
First-line: Ovulation induction with clomiphene citrate. Risk of ovarian cancer and multiple pregnancy ! (Only use in BMI<35 and only for limited period of time)
Clomiphene inhibits hypothalamic estrogen receptors, thereby blocking the normal negative feedback effect of estrogen → increased pulsatile secretion of GnRH → increased FSH and LH, which stimulates ovulation.
Metformin - improves insulin sensitivity in the short term and may improve menstrual disturbance and ovulatory function but does not have a significant impact on hirsutism and acne. metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
Second line : Ovarian drilling -
What is the treatement for hirsuitism in PCOS
- a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
- if doesn’t respond to COC then topical eflornithine (anti androgen) may be tried
- spironolactone, flutamide and finasteride may be used under specialist supervision
