PCOS

Question 1

What is PCOS?

Answer 1

Oligomenhorea / amenhorrea with hyperandrogenism (biochemical and clinical).

Frequently associated with obesity, insulin resistance, T2DM, HTN, dyslipidaemia.

Most common cause of infertility in women. 6-8% of women.

Question 2

What is the aetiology of PCOS?

Answer 2

Environmental factors: diet, exercise, obesity

Genetic factors: regulation in insulin, gonadotrophin, androgen sensitivity

Question 3

What would you find in the Hx and exam of PCOS?

Answer 3

Hirsutism: hair loss in male pattern, hair growth in male patter, deepened voice, amenhorrea/oligomenhorrea

Infertility, dysfunctional uterine bleeding, anovulation symtpoms (oligomenhorrea)

General: BMI, BP, Features of hirsutism (acne, hair pattern)

Acanthrosis nigricans due to persistant hyperinsulinaemia – velvety pigmented patches on neck and axilla. Rarely.

Question 4

What is the pathology of PCOS?

Answer 4

Hyperinsulinaemia -> increased ovarian androgen synthesis AND reduced SHBG synthesis by the liver (= higher levels of free androgen)

Question 5

What Ix do you do for PCOS?

Answer 5

Bloods: LH HIGH! LH:FSH ratio >3T3/T4 (hyper or hypothyroid). OES, androstenedione, SHBG, testosterone.

DDX: Cortisol (if Cushing’s is suspected). Prolactin (rule out hyperprolactinaemia). T3/T4 (hyper or hypothyroid).

TVUSS: 12+ cysts in both ovaries, or ovarian volume >10mL.

Question 6

What management do you do for PCOS?

Answer 6

Lifestyle: Weight loss, Exercise, Stop smoking

Pharmacological

· COCP (Dianette/ Yazmin): treat amenhorea + hirsutism. Use antiandrogenic contraceptives.

· Mirena

· Anti androgen agent can be added (ie. Spironolactone or cypropetrone) if required.

· Clomifene citrate (induce ovulation if not restored with OCP and weight loss.)

· ?Metformin may be appropriate for overweight patients

· Eflornithine hydrochloride (vaniqua) to prevent hair growth

Cosmetic- laser and electrolysis

Question 7

What are the complications/ prognosis of PCOS?

Answer 7

Infertility, Recurrent miscarriage. Endometrial carcinoma. Complications of obesity: CVS disease, DM, obstructive sleep apnoea. Usually good response to treatment.

Question 8

How do you diagnose PCOS?

Answer 8

Rotterdam criteria

• PCO (by itself is not syndrome)
• Ano or oligo ovulation or menorrhoea
• S/S of hyperandrogenism

Question 9

What are the features of PCOS?

Answer 9

Irregular cycles
Infertility
Hirsutism
Acne
Obesity

Question 10

Link to metabolic dysfunction

Answer 10

Calories in PCOS women are turned into heat less than normal women and more likely to be stored in fat

Question 11

What are the long term consequences of PCOS?

Answer 11

1. Diabetes (GDM and T2DM)
   RFs: obesity, >40, oligo/ amenorrhoea, GDM, FHx SO SCREEN!
2. CVS disease (higher lifetime risk, more common in PCOS, endoethelial dysfunction and arterial stiffness)
3. Endometrial carcinoma (RFs: infrequent periods, nulliparity, T2DM, obesity)

Question 12

What is the US evidence of PCOS?

Answer 12

• > 20 (antral) follicles <10mm in any one ovary

- Ovarian vol >10ml

Question 13

What are the biochemical findings in PCOS?

Answer 13

Normal FSH and Oestradiol
High LH

Raised LH:FSH is NOT diagnostic

Insulin (series) High

Prolactin normal or raised (menstrual disturbance but <1000)

TFTs normal

Testosterone High

Androstenedione High

SHBG low (reflects liver fat)

17OHprog normal

Question 14

How do you manage anovulation?

Answer 14

Anti oestrogens
Lap ovarian diathermy
Gonadotrophins

IVF

Question 15

How can metformin help?

Answer 15

Ovulation frequency increased

BUT conception much less than clomifene

and not good for antiandrogen