Gynecology Flashcards
1
Q
Ages menarche and menopause
A
Menarche - avg. onset age 12
Menopause - avg. onset 51 yr
2
Q
Primary vs. secondary amenorrhea
A
Primary
- no menses by age 16 with secondary sexual characteristics
- no menses by age 14 with normal secondary sexual characteristics
Secondary
- cessation of previously normal menses >6mo or no menses for 3+ normal cycles
3
Q
Thelarche
A
- breast development, begins age 9-11
4
Q
Tanner staging for breast
A
None Breast bud Increase size areola and breasts Secondary mound of areola and papilla Areola recessed to contour of breast
5
Q
Tanner staging pubic hair
A
None
Downy hair along labia
Darker/coarse hair extends over pubis
Adult-type hair covers smaller areas (no thigh)
Adult hair in quantity and type, extends over thighs
(pubarche = pubic and axillary hair, age 11-12)
6
Q
Sheehan syndrome
A
Postpartum pituitary necrosis after significant PPH (secondary amenorrhea)
7
Q
Asherman syndrome
A
Intrauterine adhesions after endometritis, D&C, or scarring after delivery (secondary amenorrhea)
8
Q
Dysmenorrhea
A
Painful menstruation of uterine origin
9
Q
Turner syndrome
A
45 XO
gonadal dysgenesis
10
Q
Swyer syndrome
A
46 XY
gonadal dysgenesis
11
Q
PCOS diagnostic criteria
A
2/3
- chronic anovulation
- biochemical (elevated testosterone) or physical signs of hyperandreogenism
- polycystic ovaries seen on ultrasound
12
Q
Primary ovarian insufficiency (POI)
A
- elevated FSH, decreased estrogen
- often intermittent ovarian function (can become pregnant)
- hormone replacement therapy until menopause
13
Q
Functional hypothalamic amenorrhea (FHA)
A
- decreased FSH and estrogen
- dx exclusion
- suppression of pulsatile GnRH secretion from hypothalamus
14
Q
Primary dysmenorrhea
A
- menses pain not because organic disease
- ovulatory cycles, improves third decade and after childbirth
- beings 6mo - 2yr after menarche
- pain due to prolonged myometrial uterine contractions and reduced blood flow to myometrium
- induced by increased prostaglandins production in secretory endometrium during ovulatory cycles
15
Q
First line tx dysmenorrhea
A
NSAIDS and/or OCPs
16
Q
Menorrhagia
A
Prolonged (>7d) or excessive (>80mL) bleeding occurring at regular intervals
17
Q
Metrorrhagia
A
Bleeding occurring at irregular intervals
18
Q
Menometrorrhagia
A
Excessive bleeding during normal menses and at other irregular intervals
19
Q
Polymenorrhea
A
Bleeding at intervals <21d
20
Q
Intermenstrual bleeding
A
Bleeding between regular cycles
21
Q
Postcoital
A
Bleeding after vaginal intercourse
22
Q
Postmenopausal
A
Any bleeding following menopause
23
Q
DVB
A
Abnormal bleeding not due to organic disease (dx exclusion)
24
Q
Change in ovarian function with perimenopause and menopause
A
Perimenopause - decrease ovarian follicle pool -> decrease inhibit -> increase FSH -> less FSH receptors in reduced follicle number -> poor dominant follicle development -> anovulatory cycles = irregular menses
Menopause - depleted ovarian reserve -> chronic anovulatory cycles -> E and P deficiency (no corpus leuteum)
25
Postmenopausal vaginal bleeding
Endometrial cancer until proven otherwise
26
Investigation of bleeding at >20wk gestation
US to r/o placenta previa BEFORE pelvic exam
27
Rx ovulatory abnormal vaginal bleeding
NSAIDs - endometrial PG = reduced menstrual flow
Antifibrinolytics - reduce menstrual bleeding
Mirena IUD - reversible blockade of plasminogen = reduced menstrual loss
28
Premenstrual Dysphoric Disorder
PMDD = severe form of PMS
- primarily mood sx
- >2 consecutive cycles in premenstrual phase
29
Premenstrual Syndrome
At least 1 affective and 1 somatic sx during the 5d before menses in 3 prior menstrual cycles
Sx relieved within 4d menses onset
30
Barrier methods contraception (failure rate)
Male condom (typical 18%, perfect 2%)
Female condom (typical 21%, perfect 5%)
Diaphragm (typical 12%, perfect 6%)
Cervical Cap ( typical: multip 23%, nullip 13%; perfect multip 26%, nullip 9%)
Sponge (typical multip 24%, nullip 12%; perfect multip 20%, nullip 9%)
Spermicide (typical 28%, perfect 18%)
31
OCP effectiveness
Perfect use = 99.9%
Typical use = failure rate 3-8%
OCP
- P component main reason for contraceptive effect
- Fertility 1-3mo after d/c
32
Combined contraceptives (failure rate)
```
Patch (typical 8%, perfect 0.3%)
Vaginal ring (typical 6%, perfect 0.3%)
```
33
P only contraception
Injectable - failure rate <0.3%/yr
Oral - failure rate typical 5-10%, perfect 0.5%
inhibits secretion of pituitary gonadotropins = suppress ovulation, increase viscosity cervical mucous, induces decidualization of endometrium
34
IUD
- if pregnancy, risk of ectopic high
Copper - failure rate 0.8%
- foreign body reaction (sterile inflammation), copper ions affect sperm motility
LNG - failure rate 0.1%
- foreign body reaction and endometrial decidualization and glandular atrophy; endometrial E and P receptor suppression thickened cervical mucous; ovulation inhibition
35
Plan B EC
Levonorgestrel-only method (2 doses 750 micrograms 12h apart OR single dose 1.5mg), approved by Health Canada
36
Stillbirth
Death >20wk GA or weighing >500g
37
Spontaneous abortion/ miscarriage
Pregnancy which ends spontaneously before fetus reaches 500g or 20 wk GA
38
Intrauterine fetal demise
Pregnancy ends spontaneously after 10-20wk
39
How many miscarriages occur in first 12wk of pregnancy?
80%
40
% spontaneous abortion due to chromosomal anomalies?
50%
41
Types of miscarriage
```
Missed abortion
Complete abortion
Incomplete abortion
Threatened abortion
Inevitable abortion
Septic abortion
Recurrent pregnancy loss
```
+/- Rhogam if Rh- mom
42
Missed abortion
no bleeding, cervix closed
death of fetus in uterus with retention of pregnancy
anembryonic pregnancy is type with gestational sac but no fetal pole
- watch and wait
- Misoprostol 400-800 μg PO/PV
- D&C ± oxytocin
43
Complete abortion
bleeding + complete passage of sac and placenta; cervix closed, bleeding stopped
spontaneous expulsion of all fetal and placental tissue before 20wk GA
- expectant management
44
Incomplete abortion
very heavy bleeding and cramps +/- passage of tissue; cervix open
incomplete expulsion of products of conception before 20wk GA
- watch and wait
- Misoprostol 400-800 μg PO/PV
- D&C ± oxytocin
45
Threatened abortion
vaginal bleeding and cramping, cervix closed and soft
bleeding during first 20wk GA without passage of tissue or cervical dilation; presence of fetal cardiac activity (high proportion of pregnancies continue)
- 30-40% all pregnancies
- watch and wait (<5% abort)
46
Inevitable abortion
bleeding and cramps +/- rupture of membranes; cervix external os opens when start to expel products
bleeding +/- ROM accompanied by cramping and dilation of cervix; gestational tissue may be seen through internal os
- watch and wait
- Misoprostol 400-800 μg PO/PV
- D&C ± oxytocin
47
Septic abortion
contents of uterus infected
infection of retained products of conception by S. aureus, GN bacilli, or GP cocci
infection can cause peritonitis and sepsis
- D&C
- IV broad spectrum antibiotics
48
Recurrent pregnancy loss
>=3 spontaneous consecutive first trimester losses
Investigations - thrombophilic, immunologic, endocrine (DM, thyroid, hyperprolactinemia), genetic/ chromosomal, anatomic (septate uterus, leiomyomas, intrauterine synechiae), environmental/toxicologic
-> evaluate mechanical, genetic,
environmental, and other risk factors
49
Menopause
12 consecutive months of amenorrhea due to loss of ovarian function
- ovulation ceases -> ovaries stop producing estradiol and progesterone but continue to produce testosterone -> small amount of E from peripheral conversion (adipose tissue) of adrenal steroids
- increased FSH and LH, reduced estradiol, increased vaginal pH >6
* screen for osteoporosis
50
Osteoporosis vs osteopenia
```
Osteoporosis = BMD >2.5 SD below young adult mean (T score at or below -2.5)
Osteopenia = BMD 1-2.5 SD below young adult mean *t score btw -1 and -2.5)
```
51
Osteoporosis tx
```
Vit D + Ca++
Bisphosphonates (alendronate, risedronate)
SERMs
Calcitonin
Estrogen
```
52
Can you rx unopposed E to women with intact uterus?
NO
53
Can you rx P along in pt with breast CA?
NO
54
Amsel criteria (BV)
3/4
- thin homogenous vaginal d/c
- clue cells in n/s wet mount or gram stain
- positive Whiff test on KOH wet mount (fishy)
- vaginal pH >4.5
55
BV
- G. vaginalis
- Bacteroids
- Peptostreptococcus
- M. hominis
increased risk of preterm birth (tx in pregnancy)
tx - metronidazole or clindamycin
56
Vaginal trichomoniasis
T. vaginalis
- facilitates HIV transmission, associated with PROM
- strawberry cervix on exam
tx - metronidazole
57
Gonorrhea
- N. gonorrhea (diplococci)
- perihepatitis (Fitz-Hugh-Curtis)
- can be disseminated
incubation period 2-7d
dx - nucleic acid testing from endocervical specimen; gram stain swab; culture
tx- ceftriaxone 250mg IM
58
Chlamydia
- C. trachomatis
- serotypes D, E, F, G, H, I, J, K (obligate intracellular bacteria)
- often asymptomatic
incubation period up to 6wk
dx- nucleic acid testing assay from endocervical, urethral or urinary specimen; culture
tx- azithromycin 1g PO
59
Syphilis
- painless ulcer, resolves 2-8wk
- incubation period 3-90d
- dark field microscopy of serous fluid form genital lesions for observation of spirochetes
tx- benzathine penicillin or doxycycline
60
Secondary syphilis
- widespread symmetric maculopapular rash (palms, soles), fever, malaise, LAD, mucous lesions, condylomata late, alopecia, meningitis, headaches, uveitis, retinitis
- incubation 2wk - 6mo
VDRL and RPR test
61
Neurosyphilis
Argyll-Robertson pupil
incubation 2-20yr
tx - Penicillin G
62
Gumma
- form of tertiary syphilis - tissue destruction in any organ
- Pen G + treat sexual contacts last 30d
63
Herpes (HSV1, HSV2) and chancroid
painful genital ulcers
MUST inform sexual partners from preceding 60d before sx (risk asymptotic shedding)
- culture HSV lesion, HSV PCR, NAAT assay
tx - acyclovir, famcoclovir
Chancroid - H. ducreyi (cofactor HIV)
- painful genital ulcer with granulomatous base
- incubation 5-14d
- gram stain GN coccobacilli with 'school of fish' pattern
tx - ciprofloxacin, erythromycin, azithromycin, ceftriaxone
64
HPV
```
warts = condyloma acuminata
Subtypes:
- low risk = 6, 11, 41, 44
- intermediate risk = 31, 33, 35
- high risk = 16, 18, 45, 56
```
Intraepithelial lesions on Pap -> cervical involvement (LSIL, HSIL, invasive carcinoma)
tx - Imiquimod, cryotherapy, CO2 laser ablation, excision, etc
65
PID
- C. trachomatis, N. gonorrhoea, other (E. coli, Peptostreptococcus, G. vaginalis, etc.)
```
Minimum triad
- adnexal tenderness
- cervical motion tenderness
- uterine tenderness
gold standard dx = laparoscopy
```
tx - ceftriaxone + doxycycline or azithromycin; levofloxacin; cefoxitin + doxycycline
66
Fitz-Hugh-Curtis syndrome
perihepatitis resulting in adhesions between liver capsule and abdo wall; resolves with rx of PID
67
Cervical CA
90% SCC
10% adenocarcinoma
Pap test to detect abnormal cervical cells (age 21 - 69)
- long precancerous phase
- HPV 16, 18 most commonly in malignant lesions
68
Colposcopy
Magnification of transformation zone
3-5% acetic acid then Lugol solution
Biopsy of abnormal epithelium
85-95% accurate (vs. Pap 15-40% false negative)
69
Molar pregnancy
+ B-hCG
no FHR
U/S showing snowstorm
70
Leiomyoma
Uterine fibroid
subtypes:
- cervical, broad ligament, pedunculate subserous, subserous, submucous, interstitial or intramural, fibroid polyp pedunculate submucous
40% symptomatic: AUB, pressure/compromise of pelvic organs, increased irritative voiding sx (UTI), increase abdo size, acute pelvic pain (fibroid torsion or degeneration), infertility
60% asx: fibroid <6cm or stable size, not located in submucosa
71
Imaging in pelvic masses
US - first choice, delineates mass qualities, assess for ascites, safe in pregnancy
CT - suboptimal for ovary, assess other organs and LN, assess retroperitoneum
MRI - identify soft tissue lesions, safe in pregnancy
72
Ovarian mass lab markers
CA-125
- glycoprotein produced by fetal coelomic epithelium
- normal <35 U/mL
- increased in epithelial cell ovarian tumors (increased in 85% ovarian CAs)
- elevated in: fibroids, PID endometriosis, cirrhosis, adenomyosis, pregnancy, appendicitis, breast/ lung/ ovarian/ colon/ fallopian tube CAs, pancreatitis, renal failure, ascites
AFP
- major protein in fetal serum, NOT detectable after birth
- <5.4 ng/mL normal
- elevated in germ cell tumors (increased in 85% germ cell tumors)
- also elevated in dermoids, pregnancy, HCC
LDH
- enzyme found in almost all body tissue
- normally <250 U/L
- elevated in dysgerminomas
hCG
- normally produced by placenta
- normal <5 mIU/mL
- elevated in germ cell tumors GTD (elevated 80% germ cell tumors); also in pregnancy and marijuana use
73
RF ovarian cancer
80% epitheial cell tumors
rf:
- FHx ovarian Ca
- excess ovulation
- increasing age
- Lynch II syndrome (familial disposition to endometrial, ovarian and GU CAs)
- BRCA1 (chr17q) and BRCA2 (chr13q) tumor suppressor gene mutations (familial breast and ovarian CA)
74
Chronic pelvic pain
- pain below umbilicus in pelvis
- pain lasting >6mo
- pain severe enough to interfere with quality of life or daily functioning
ddx:
- gyne (endometriosis, chronic PID, adenomyosis, leiomyomata, dysmenorrhea, etc.)
- GI (IBS, IBD, diverticulitis, etc.)
- uro (chronic UTIs, interstitial cystitis, etc.)
- msk (fibro, nerve entrapment, etc.)
- systemic (sleep disturbance, mental health)
depression can co-excist and approx 25% pt with CPP have hx sexual/ physical abuse
75
Common locations of ectopic pregnancy
```
ampullary 70%
isthmic 12%
fimbrial 11%
ovarian 3%
other - interstitial, abdo, cervical
```
need b-hCG >1500 mIU/mL
76
RF ectopic pregnancy
- previous EP
- current IUD
- hx PID
- prev. tubal surgery
- in utero DES exposure
- infertility
- smoking
- uterine structure (fibroids, adhesions, etc.)
77
Management ectopic pregnancy
methotrexate (MTX)
- folic acid antagonist (inhibits DNA synthesis and cell reproduction)
- if: hemodynamically stable, no bleeding, <3.5cm enraptured mass, no fetal heart activity, b-hCG <5000, future fertility desired, pt compliant
monitor with weekly b-hCG until not detectable
laparoscopic surgery or laparotomy
- salpingostomy vs. salpingectomy
- if fail MTX or previous EP in same fallopian tube
78
Types of pelvic prolapse
Cystocele - herniation of bladder with associated descent of anterior vaginal segment
Uterine prolapse - descent of uterus and cervix
Vaginal vault prolapse - descent of vaginal apex
Rectocele - herniation of rectum with associated descent of posterior vaginal segment
Enterocoele - herniation of small bowel with associated descent of posterior vaginal segment
79
Occult/latent incontinence
Incompetent urethral sphincter kinked by prolapse and when prolapse is repaired it results in new onset of stress incontinence
80
PVR normal vs. impaired bladder emptying
If initial voided volume >150mL then PVR <100mL = appropriate bladder emptying
- If PVR >100mL then impaired bladder emptying
81
Muscular pelvic floor components
Levator and (puborectalis, pubococcygeus, iliococcygeus) and coccygeus muscles attached to bony pelvis, coccyx, scarum
82
Prolapse management
```
Conservative - f/u, behavioural changes
Nonsurgical
- Pelvic floor muscle training
- Pessaries (support and space-filling)
Surgical
```
83
Urinary incontinence
Involuntary loss of urine
84
Stress incontinence (SI)
Involuntary leakage of urine during effort, exertion, sneezing, or coughing
tx- behavioural (lifestyle, Kegel, biofeedback), medical (?), devices (pessaries), surgical
85
Urodynamic SI
SI confirmed during urodynamic testing by identifying leakage from urethra coincident with increased intraabdominal pressure, but in absence of bladder contraction
86
Urge incontinence
Involuntary loss of urine with a strong desire to void
- involuntary bladder contractions (detrusor overactivity) are hallmark of dx
tx - lifestyle, behavioural (bladder retraining, Kegel, biofeedback), medical (TCAs, anticholingeric, selective B-receptor agonist), surgical (sacral nerve modulation), botox injections into bladder
87
Overflow incontinence
Large volume of urine in bladder due to incomplete emptying
88
Continuous incontinence
Continuous leakage of urine due to vesicovaginal fistula
89
Infertility
Inability to conceive after 1yr of regular intercourse without contraception (unless >35, irregular/ infrequent menses, hx PID or endometriosis)
affects 15% couples (female = 50% problems, males = 35% problems, unexplained = 10-15%)
90
Fecundability, fecundity
Fecundability - probability a single cycle will result in pregnancy (20-25%)
Fecundity - probability that a single cycle will result in a live birth
91
Menstrual cycle
menstrual phase - 1-4d
follicular phase - 5-13d
ovulation - 14d
luteal phase 15-28d
92
What rx will induce ovulation?
Clomiphene citrate
| Gonadotropins
93
IVF indications
```
Severe tubal disease
Advanced stage endometriosis
Severe male factor
Multifactor infertility
Age-related or otherwise unexplained subfertility
POI (with young donor egg)
```
94
Musculature of external vagina/ anus?
- ischiocavernosus muscle
- bulbospingiosus muscle
- superficial transverse perineal muscle
- levator ani muscle
- external anal sphincter
95
Blood supply/ sensory innervation/ lymphatics to external female genetalia?
- internal pudendal artery
- pudendal nerve
- inguinal nodes
96
Lining of vagina?
- rugated squamous cell epi
97
Blood supply to vagina?
blood supply: vaginal branch of internal pudendal artery with anastamoses from uterine, inferior vesical, and middle rectal arteries
98
2 major parts of cervix? Blood supply?
Uterine corpus
- blood supply: uterine artery (branch of the internal iliac artery)
Cervix
- blood supply: cervical branch of uterine artery
99
4 uterine ligaments? Function? Blood supply?
Round ligament: travel from anterior surface of uterus, through broad ligaments, and
inguinal canals then terminate in the labia majora
- function: anteversion
- blood supply: Sampson’s artery (branch of uterine artery running through round ligament)
Uterosacral ligament: arise from sacral fascia and insert into posterior inferior uterus
- function: mechanical support for uterus and contain autonomic nerve fibres
Cardinal ligament: extend from lateral pelvic walls and insert into lateral cervix and vagina
- function: mechanical support, prevent prolapse
Broad ligament: pass from lateral pelvic wall to sides of uterus; contain fallopian tube, round ligament, ovarian ligament, nerves, vessels, and lymphatics
100
What ligament connects ovary to pelvic wall?
Infundibulopelvic ligament
- continuous tissue that connects ovary to pelvic wall
- contains the ovarian artery, ovarian vein, ovarian plexus, and lymphatic vessels
101
Are ureters anterior or posterior to uterine arteries?
Posterior
| - water under the bridge
102
Segments of fallopian tubes? Blood supply?
- interstitial segment
- isthmic segment
- ampullary segment
- infundibular segment
- terminates at fimbriae
blood supply: uterine and ovarian arteries
103
What is the mesosalpinx?
- peritoneal fold that attaches fallopian tube to broad ligament
104
What are the two sections in an ovary? What ligament supports the ovary? Blood supply (arteries/veins)?
• consist of cortex with ova and medulla with blood supply
• supported by infundibulopelvic ligament (suspensory ligament of ovary)
• blood supply: ovarian arteries (branches off aorta)
- left ovarian vein (drains into left renal vein),
- right ovarian vein (drains into inferior vena cava)
105
What is the mesovarium?
- peritoneal fold that attaches the ovary to the broad ligament
106
Female stages of puberty?
"Boobs, Pubes, Grow, Flow"
Thelarche, Pubarche, Growth spurt,
Menarche
107
Tanner Stage
- Thelarche
- Pubarche
Thelarche
I. None
II. Breast bud
III. Further enlargement of areola and breasts with no separation of contours
IV. 2º mound of areola and papilla
V. Areola recessed to general contour of breast – adult
Pubarche
I. None
II. Downy hair along labia only
III. Darker/coarse hair extends over pubis
IV. Adult type covers smaller area, no thigh involvement
V. Adult hair in quantity and type; extends over thighs
108
What hormone triggers menses?
Progesterone withdrawal
109
Hormones in mid-follicular phase?
- Estrogen from follicles (ovary)
| - Increased FSH -> acts on ovarian granulose cells
110
When does the dominant follicle persist? Hormone changes?
Late follicular phase
- other follicles (not dominant) undergo atresia
- increased E from dominant follicle -> builds up endometrium
- granulose cells luteinze -> produce P
111
When do LH and FSH peak?
Day 14
| - switch from negative to positive feedback (E and P increase LH and FSH)
112
Hormones with ovulation?
- E peaks -> LH surge -> ovulation
113
What produces P in luteal phase?
Corpus luteum from dominant follicle
| - P stabilizes endometrium
114
Subsequent hormone changes after no fertilization?
Reduced P due to degeneration of corpus luteum -> P withdrawal = menses
115
Normal blood loss per menses?
25-80 mL
116
Estrogen in the menstrual cycle
| - effects
ESTROGEN is the main hormone in the follicular/proliferative phase and is stimulated by FSH. As the level increases it acts negatively on FSH. The majority of estrogen is secreted by the dominant follicle
Estrogen effects
• On the follicles in the ovaries = reduces atresia
• On the endometrium= proliferation of glandular and stromal tissue
• On all target tissues = decreases E receptors
117
Progesterone in menstrual cycle
| - effects
PROGESTERONE is the main hormone in the luteal/secretory phase and is stimulated by LH. Increased progesterone acts negatively on LH and is secreted by the corpus luteum (remnant of dominant follicle)
Progesterone effects
• On the endometrium: cessation of mitoses (stops building endometrium up);
“Organization” of glands (initiates secretions from glands);
Inhibits macrophages, interleukin-8, and enzymes from degrading endometrium
• On all target tissues: decrease E receptors (the “anti-estrogen” effect); decrease P receptors
118
Define Asherman's syndrome
Adhesions within the endometrial cavity causing amenorrhea/infertility
119
Sites of ectopic implantation
Ampullary (70%) >> isthmal (12%) > fimbrial (11%) > ovarian (3%) > interstitial (2%) > abdominal (1%)
120
When rx Methotrexate for ectopic pregnancy?
```
<3.5 cm unruptured ectopic
AND no fetal heart rate
AND β-hCG <5,000
AND no hepatic/renal/hematological disease
AND compliance assured
AND able and willing to follow-up
```
121
How do you confirm ovulation?
day 21-23: serum progesterone
122
What can you use to induce ovulation?
clomiphene citrate (Clomid®): estrogen antagonist that causes a perceived decreased estrogen state, resulting in increased pituitary gonadotropins; causes increased FSH and LH, leading to ovulation induction (works much better if anovulatory)
123
Normal semen analysis?
Normal Semen Analysis (WHO lower reference limits)
• Must be obtained after 2-7 d of abstinence
• Volume 1.5 cc
• Count 15 million/cc
• Vitality 58% live
• Motility 32% progressive, 40% total (progressive + non-progressive)
• Morphology 4.0% normal
124
Results of increased estrogen in PCOS?
obesity -> increased E -> increased LH, decreased FSH -> anovulation -> infertility
-> and increased ovarian androgens -> hisuitism
125
Criteria to dx PCOS (Rotterdam)?
Rotterdam diagnostic criteria: 2 of 3 required
- oligomenorrhea/irregular menses for 6 mo
- hyperandrogenism
-> clinical evidence - hirsutism or male pattern alopecia or
-> biochemical evidence - raised free testosterone
- polycystic ovaries on U/S
