Metabolic Syndrome / PCOS (4 questions)

Question 1

What are the diagnostic criteria for PCOS?

Answer 1

Diagnosis of exclusion!

The Rotterdam Criteria (2 out of 3)

1. Irregular periods (chronic)
2. Clinical and/or biochemical hyperandrogenism
   
   • Acne
   • hirsutism
   • Androgenetic alopecia (thinning hair of the top of the scalp)
3. Polycystic Ovarian Morphology (PCOM), visualized by TVUS (ovarian volume >10mL and/or >12 follicles <9mm in size in at least one ovary)

Exclusion of differential diagnoses

Question 2

Clinical manifestions of PCOS

Answer 2

• Oligomenorrhea (more than 35 day intervals or less than 8 menses in 1 yr)
• Excessive body hair (hirsutism)
• Acne (especially acne of the upper back in women that are not of adolescent age)
• Thinning of scalp hair (usually noticed as widening of the central part)
• Obesity
• Galactorrhea
• Depression
• Skin tag (clinical mark of insulin resistance)
• Striae
• Elevated BP
• Insulin resistance (get a 2hr GCT for all patients with suspected PCOS)
• Increased risk for complicated pregnancy (embolism, fetal macrosomia, miscarriage, etc)

Question 3

Mgmt of PCOS

Answer 3

• Lifestyle: weight loss, exercise, stress reduction
• Combined hormonal contraceptives: go for one with low androgenicity (Spirinolactone, Finesteride) or antiandrogen (drosperinone) (endometrial protection)
• Progestin-only pills, Mirena, Depo
• Metformin
• Vit D
• Glucocorticoids
• GnRH agonist
• Topical: Vaniqa (removes hair), depilation

Question 4

What is oligomenorrhea?

Answer 4

less than 8 in a year of >35 days. Should be longstanding – always irregular, e.g., OCP at young age to regulate, off now and again irregular

Question 5

DDx for PCOS

Answer 5

• Hypothyroidism
• Hyperprolactinemia
• Late onset CAH
• Androgen secreting tumor
  
  • Ovarian
  • Adrenal
• Cushing Syndrome
• Iatrogenic

Question 6

R/O tests indicated in PCOS

Answer 6

• • TSH
    
    • Prolactin
    • 17OHP
    • 24 hour UFC?
    • Androgen tumor
    • Pregnancy
    • FSH/LH - r/o primary ovarian failure

Question 7

Diagnostic tests in PCOS

Answer 7

Diagnosis of exclusion! But you could look at:

• Androgens: Total & Free T (expect overproduction), DHEAS (normal or slightly high)
• Also look at OGTT, lipids - high risk population

Question 8

What clinical signs would lead you to consider a different etiology?

Answer 8

Rapid onset of hirsutism / hyperandrogenism after 30yo

Virilization: deepening of voice, clitoromegaly (?androgen secreting tumor)