Hirsutism and PCOS

Question 1

Diagnosis of PCOS

Answer 1

Rotterdam Criteria 2003
At least 2 of:
Clinical/biochemical evidence of hyperandrogenism 
Oligo/Anovulation 
Presence of Polycystic Ovaries on USS

Question 2

Pathophysiology of PCOS

Answer 2

Multiple cysts within ovaries from arrested follicular development and excessive androgen production from ovaries and adrenal glands
Thought to be due to increased frequency of GnRH pulse generator leading to increased LH pulses and androgen secretion
LH is raised in 40% and testosterone in 30%

Question 3

Other health associations with PCOS

Answer 3

Hyperinsulinemia, insulin resistance, metabolic syndrome (HTN, hyperlipidaemia, CV risk)
40% have impaired glucose tolerance or diabetes by 40 years
All are at risk especially obese
GTT by 20 weeks for pregnant women with PCOS
SHBG might be low due to high insulin levels and increased free androgen levels

Question 4

Presentation of PCOS

Answer 4

Amenorrhoea/Oligomenorrhoea
Hirsutism
Acne shortly after menarche
Hirsutism should be recorded objectively and monitored
Hirsutism usually beings at time of menarche and increases slowly and steadily into teenage years
Virilisation: Clitoromegaly, frontal balding
Obesity
Acanthosis Nigricans

Question 5

Investigation of Hirsutism and PCOS

Answer 5

Basal (day2-5) serum total testosterone, FSH, LH, TFTs, Prolactin
Hyperandrogenic: SHBG, Androstenedione, DHEA-S
Ovarian US
Dexamethasone suppression
CT/MRI of adrenals if virilising tumour suspected

Question 6

Management of Hirsutism:

Local Therapy

Answer 6

Plucking, bleaching, creams, waxing, shaving, electrolysis, laser hair removal

Question 7

Management of Hirsutism and PCOS: Systemic

Answer 7

Oral contraceptives suppress androgen production and reduce free androgen by increasing SHBG levels

Question 8

Management of Menstrual Disturbance

Answer 8

Oral contraceptives

Metformin 500mg TDS

Question 9

Management for Fertility

Answer 9

Metformin alone might improve ovulation and chance of conception
Clomiphene on days2-6 of cycle increases chance of achieving ovulation (not recommend for >6 cycles)
Reversal of circadian rhythm with prednisolone which suppresses ACTH production

Question 10

Normal hair vs. hirsutism

Answer 10

Soft vellus hair is normally present all over the body and is not sex hormone dependent
Hair in beard, moustache, breast, chest, axilla, abdominal midline pubic or thigh areas are sex hormone dependent
Excess is hence marker of increased ovarian or adrenal androgens

Question 11

Idiopathic Hirsutism

Answer 11

No elevation in Serum Androgen and no other clinical features
o Familial typically involves distribution non-typical of Androgenic growth

Question 12

Rarer endocrine causes

Answer 12

CAH
Cushing's Syndrome 
Thyroid Dysfunction 
Hyperprolactinemia 
Virilising Tumours of the Ovary and Adrenal Glands

Question 13

Ovarian Hyperthecosis

Answer 13

Non malignant
Luteinised Theca Cells which secrete testosterone
Like PCOS presentation but typically in perimenopausal women
Serum testosterone higher than typically seen in PCOS

Question 14

Iatrogenic causes of hirsutism

Answer 14

Androgens
Weakly androgenic: Progestogens
Non-androgen dependent growth: phenytoin, diazoxide, ciclosporin