PCOS ☺️

Question 1

Epidemiology, description

Etiology

Answer 1

Ovarian dysfunction affecting up to 20% of menstruating women
Aetiology unclear

Question 2

Presentation of PCOS

Investigations

Answer 2

Sub/infertility
Oligomenorrhea, amenorrhea 
Hirsuitism, acne on back (high androgen)
Obesity
Acanthosis nigricans (DM)

NO DEFINTIVE TEST, clinical diagnosis on the results of investigations

Total T (high), sex hormone binding globulin (low)
-use this to calculate free androgen index => work out amount of physiologically active T

FSH, LH => rule out other causes of menstruation problems
-high in POI
-low in hypogonadotrophic hypogonadism
PRL => rule out high PRL
TSH, T3,4 => rule out hypothyroidism

TVUS => 12+ follicles in 1 ovary (presence or absence does not establish diagnosis)

Signs of virilization => rule out CAH, androgen secreting tumours
Signs of hirsuitism => rule out Cushings

Question 3

Differential diagnoses

Answer 3

Iatrogenic/idiopathic
-High dose androgenic drugs => T, anabolic steroids

Neoplastic
-Androgen secreting tumour => high A, clitoromegaly, hirsuitism, male pattern hair loss

Endocrine/environmental

• Primary hypothyroidism => oligo/amenorrhea, goitre, high PRL, A
• POI => normal A, oligo/amenorrhea, high FSH, LH, low O, P
• Hyperprolactinemia => galactorrhea, oligo/amenorrhea, high PRL
• Adrenal hyperplasia => high A
• Cushing => high A, oligo/amenorrhea, HTN, striae, easy bruising, high cortisol
• Hypogonadotrophic hypogonadism => low GnRH, O, P, FSH, LH

Functional
-pregnancy, lactation, menopause => amenorrhea

Question 4

Diagnostic criteria for PCOS

Answer 4

After investigations

• other causes of menstrual disturbance, hyperandrogenism excluded
• infrequent/no ovulation
• clinical/biochemical signs of hyperandrogenism
• 12+ follicles found on either ovary +- increased ovarian volume

Question 5

Management - lifestyle, screening, monitoring

Answer 5

Lifestyle to reduce risk of complications, improve clinical features of PCOS
-weight loss

Screening

• T2DM
• QRISK, HTN, smoking, drinking, cholesterol
• weight and BP monitoring

Psych
-psychosexual problems, negative body image, EDs

Question 6

Monitoring - pharmacological

Answer 6

Most signs will be improved with lifestyle changes but can be helped with meds
Oligo/amenorrhea => cyclical P, COC, IUS/IUD
Acne => COC, may add topical retinoids/ABx
Hirsuitism => COC
Fertility => clomiphene (encourages ovulation by inhibiting O-ve feedback)

Question 7

Complications?

Answer 7

Pregnancy risks

• HTN, PET
• GD
• miscarriage

Infertility
CVD
T2DM, metabolic syndromes
Endometrial cancer (chronic O exposure with no P protection)