Gynaecology: PCOS, Ovarian Cysts & Ovarian Torsion Flashcards
What is the most common endocrine disorder affecting women of reproductive age?
PCOS - affects 10% of women
Pathophysiology of PCOS?
Excessive androgen production and multiple ovarian cysts.
Main clinical features of PCOS?
- Anovulatory infertility
- Acne
- Hirsutism
- Irregular menstrual cycles
- Obesity
- Increased long term risks of cardiovascular events
- Increased risk of endometrial cancer
Is PCOS inherited?
Yes but the genetic inheritance of PCOS is heterogeneous and complex.
Appears to be inherited in an autosomal dominant fashion.
What is the leading environmental contributor in PCOS?
Post-natal obesity
What 2 mechanisms can lead to excess androgen production in PCOS?
Due to one or both:
1) Excess LH (luteinising hormone) production
2) Hyperinsulinemia and insulin resistance
How can hyperinsulinemia and insulin resistance lead to excess androgen production?
Excess insulin in the bloodstream promotes androgen production by the ovaries.
Hyperinsulinemia may stimulate the ovary to over-produce testosterone and prevent the follicles from growing normally to release eggs. This causes the ovaries to become polycystic.
Most women with PCOS have “cysts” found on their ovaries. What are these cysts?
These are immature follicles which have had their ovulation phase arrested.
Cause of cysts in PCOS?
This occurs due to an elevated baseline of LH and lack of LH surge (as in a normal menstrual cycle).
Risk factors for PCOS?
Obesity
Diabetes mellitus
Family history of PCOS
Premature adrenarche (early onset of pubic hair)
Define anovulation
Absence of ovulation
Define oligoovulation
irregular, infrequent ovulation
Define oligomenorrhoea
irregular, infrequent menstrual periods
define hyperandrogenism
The effects of high levels of androgens
Define hirsutism
The growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
What criteria is used for making a diagnosis of PCOS?
Rotterdam Criteria
What is the Rotterdam Criteria?
A diagnosis requires at least two of the three key features:
1) Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
2) Hyperandrogenism, characterised by hirsutism and acne
3) Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.
What triad is seen in PCOS?
1) Anovulation
2) Hyperandrogenism
3) Polycystic ovaries on US
Clinical features of PCOS?
- Acne
- Hirsutism
- Infertility
- Hair loss & male pattern baldness
- Depression and other psychological disorders
- Menstrual cycle disturbance
- Obesity (about 70% of PCOS patients)
Whjat is the most common symptom of PCOS?
Hirsutism
Where is hirsutism most commonly in PCOS?
Face, chest, and back
Other features and complications of PCOS:
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
- Increased risk of metabolic syndrome ; HTN, obesity
What is acanthosis nigricans? What is it associated with?
Thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.
Differential diagnoses of hirutism?
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
How are insulin and androgens related?
When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body.
1) Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone).
2) Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
How does insulin relate to anovulation in PCOS?
The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
What can help with insulin resistance in PCOS?
Diet, exercise and weight loss
Differentials for PCOS?
1) Thyroid dysfunction –> particularly hypothyroidism can lead to hair loss and menstrual cycle irregularities. However, hirsutism is rare.
2) Congenital adrenal hyperplasia (21-hydroxylase deficiency) –> this causes cortisol deficiency and may also lead to androgen excess, leading to a clinical picture indistinguishable from that of PCOS.
3) Cushing’s syndrome –> excess cortisol production, leading to many features similar to PCOS (e.g. weight gain, acne, hypertension, insulin resistance).
4) Hyperprolactinaemia –> can lead to changes in the menstrual cycle. Galactorrhoea is usually present.
Bedside investigations in PCOS?
hCG –> rule out pregnancy
Capillary blood glucose –> insulin resistance and TD2 can be a sequela of PCOS
What blood tests should be done in PCOS?
- Baseline blood tests: FBC, U&E, CRP
- Testosterone
- Sex hormone-binding globulin (SHBG): normal to low in PCOS
- Testosterone to SHBG ratio: may be raised
- LH and FSH: LH if often raised, and a LH:FSH ratio >3 can suggest PCOS
- Oral glucose tolerance test: to assess insulin resistance
- Lipid screen: to assess cardiovascular risk (PCOS can cause dyslipidaemia)
How will testosterone be affected in PCOS?
Raised
How will LH to FSH ratio be affected in PCOS?
Raised (high LH compared with FSH)
How will LH be affected in PCOS?
Raised
How will insulin be affected in PCOS?
Raised
Most important imaging investigation in PCOS?
Pelvic ultrasound scan
What would a pelvis US typically show in PCOS?
Classically showing ≥12 follicles (“cysts”) on the ovaries and/or increased ovarian volume (>10cm3). The follciles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.
However, the syndrome can exist without polycystic ovaries.
Gold standard investigation for visualising the ovaries?
Transvaginal US
Diagnostic criteria for PCOS from pelvic US?
1) 12 or more developing follicles in one ovary
OR
2) Ovarian volume of more than 10cm3
Who is a pelvic US not reliable in for PCOS diagnosis?
Adolescents
What is the screening test of choice for diabetes in patients with PCOS?
2-hour 75g oral glucose tolerance test (OGTT).
When is an OGTT performed?
in the morning prior to having breakfast.
What is involved in an OGTT?
It involves taking a baseline fasting plasma glucose, giving a 75g glucose drink and then measuring plasma glucose 2 hours later. It tests the ability of the body to cope with a carbohydrate meal.
What OGTT result implies an impaired fasting glucose?
Fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
What OGTT result implies an impaired glucose tolerance?
Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
What OGTT result implies diabetes?
plasma glucose at 2 hours above 11.1 mmol/l
General management of PCOS?
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease:
- Weight loss
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
Specific management options for PCOS?
COCP –> role in restoring regular menstruation, reducing the risk of endometrial hyperplasia, and reducing the effects of hyperandrogenism (such as hirsutism and acne)
Specific anti-androgens e.g. cyproterone acetate or drospirenone
Eflornithine hydrochloride (Vaniqa cream) –> useful in reducing unwanted facial hair
Metformin –> used to reduce the insulin resistance associated with PCOS, and in turn, helps to promote regular menstruation and increases fertility
Orlistat –> a pancreatic lipase inhibitor which can be used in severe cases to assist with weight loss, should conservative measures fail
Management of depression & anxiety
What plays a significant role in the management of PCOS?
Weight loss