PCOS

Question 1

Outline the diagnostic criteria for PCOS and differentials for secondary amenorrhoea and/or hyperandrogenism

Answer 1

• Dx criteria PCOS (2 out of 3): oligo- or amenorrhoea; biochem or clinical hyperandrogenism; PCO morphology on USS.
• DDx for secondary amenorrhoea:
  
  • Pregnancy
  • Hyperprolactinaemia
  • Thyroid dysfunction
  • POI
  • Structural: Asherman, cervical stenosis
  • Functional hypothalamic amenorrhoea
  • Cushing syndrome
• DDx hyperandrogenism:
  
  • Androgen secreting tumour
  • Exogenous androgen
  • CAH

Question 2

You suspect a patient has PCOS; what investigations would you perform to rule out other causes?

Answer 2

• BhCG
• FSH, LH, oestradiol, mid-luteal phase progesterone
• Testosterone, FAIS, SHBG +/- DHEAS
• Serum PRL, TFTs
• Pelvic USS
• 17-OH progesterone level (CAH)
• (Progestin withdrawal test if no other cause found ?intrauterine cause)

Question 3

Outline main risks and relevant management for women with PCOS:

Answer 3

• General:
  
  • Weight loss: dietician, exercise, green prescription, Orlistat
• Anovulation and endometrial protection if <3 periods/year:
  
  • COCP, Mirena, cyclical progesterone 12 days/month.
    
    • Pipelle if thick ET and RFs.
  • CVD and diabetes:
    
    • Regular screening: weight, BMI, abdo circumference, BP, lipids, HbA1c
  • Infertility: weight loss, ovulation induction letrozole +/- metformin, gonadotrophin therapy, laparoscopic ovarian drilling
  • Hirsuitism and acne: COCP, Ginet (cyproterone acetate), dermatologist
  • Mental health: screen for mood disorders and tx.
  • OSA: screening for snoring and day time somnolence and refer to respiratory.
  • Pregnancy:
    
    • Risks: miscarriage, GDM, PET, PTB, CS.
    • Aspirin, calcium, early OGTT, PET screening