Irregular Bleeding and PCOS

Question 1

What are some of the common aetiologies of dysfunctional uterine bleeding?

Answer 1

• PALM and COEIN
• Polyps, adenomyosis, leiomyomata, malignancy
• Coagulopathy (esp VW), ovulatory dysfunction, endometrial problems, iatrogenic, not yet classified

Question 2

What investigations might you consider initially in a woman with dysfunctional uterine bleeding?

Answer 2

• FBE/iron studies, bHCG, TVUS (TFTs, coags)

Question 3

What medical treatments are commonly used for dysfunctional uterine bleeding?

Answer 3

• NSAIDs/tranexamic acid - reduce bleeding amount
  
  • Taken during menstruation
• Progesterone (Mirena or POP/Implanon)
  
  • Take up to months for full effectiveness
• Iron supplements if required
• GnRH agonists (only if contraindications to others)

Question 4

What surgical treatments are options considered in dysfunctional uterine bleeding?

Answer 4

• Endometrial ablation
• Uterine artery embolisation
• Hysterectomy

Question 5

What are the criteria for a diagnosis of PCOS?

Answer 5

• 2+ of:
  
  • Oligo/anovulation
  • Clinical or biochemical hyperandrogenism
  • Sonographic polycystic ovaries

Question 6

What is the main underlying pathophysiology causing PCOS symptoms?

Answer 6

• LH increase, FSH lack
  
  • Ovarian testosterone production
    
    • Hirsuitism, acne, lipid derangements
    • Anovulation
  • Peripheral conversion to oestrogen
    
    • Endometrial hyperplasia, menorrhagia
• Dysregulated and non-cyclical hormonal pattern
• Insulin resistance

Question 7

What are the common presentations of someone with PCOS?

Answer 7

• Menstrual dysfunction
  
  • Oligo/amenorrhoea
  • Menorrhagia (unopposed oestrogen)
• Hyperandrogenism
• Infertility
• Metabolic syndrome
• Obstructive sleep apnoea

Question 8

What investigations might you order in someone suspected of PCOS?

Answer 8

• Diagnostic evidence - free T, total T, DHEAS
• Complications - OGTT, lipids
• Differentials - TFT, 17-OH-progesterone, prolactin

Question 9

What treatment options are available for women with PCOS?

Answer 9

• Weight loss, exercise and dietary advice
• Cycle control
  
  1. COC (or POP if contraindicated)
  2. Metformin
• Fertility
  
  1. Clomiphene +/- metformin
  2. Gonadotrophins +/- metformin
  3. IVF +/- metformin
• Anti-virilising
  
  1. COC (antiandrogenic e.g. cyproterone)
  2. Spironolactone or cyproterone