PCOS Flashcards
What is PCOS?
-PCOS is a common condition causing metabolic and reproductive problems in women
What are key characteristic features of PCOS?
- multiple ovarian cysts
- infertility
- oligomenorrhoea
- hyperandrogenism
- insulin resistance
What does anovulation refer to?
absence of ovulation
What does oligoovulation refer to?
irregular, infrequent ovulation
What does amenorrhoea refer to?
absence of menstrual periods
What does oligomenorrhoea refer to?
irregular, infrequent periods
What are androgens?
male sex hormones such as testosterone
What does hyperandrogenism refer to?
effects of high levels of androgens
What does hirsutism refer to?
growth of thick dark hair, often in a male pattern, e,g male pattern facial hair
What is the Rotterdam criteria?
-Rotterdam criteria is used to make a diagnosis of PCOS with diagnosis requiring at least 2/3 features
What are the features of the Rotterdam criteria?
- oligoovulation or anovulation presenting with irregular periods
- hyperandrogenism, charecterised by hirsutism and acne
- polycystic ovaries on US
What are the key features in presentation of PCOS?
- oligo/amenorrhoea
- infertility
- obesity (70% of pts)
- hirsutism
- acne
- hair loss in male pattern
What are other features of PCOS?
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
What is acanthosis nigricans?
- thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture.
- It occurs with insulin resistance.
It is important to rule out other causes of hirsutism, what are they?
- medications such as phenytoin, ciclosporin, corticosteroids, testosterine and anabolic steroids
- ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
How does insulin resistance further promote hyperandrogenism in PCOS?
- when insulin resistant, the pancreas responds by producing more insulin
- this insulin promotes release of androgens from the ovaries and adrenal glands
- thus higher levels of insulin lead to higher levels of androgens
- insulin also supresses sec hormone binding globulin SHBG which normally binds to androgens and suppresses their function
- all in all this halts development of follicles in ovaries leading to annovulation and multiple partially developed follicles
What can help reduce insulin resistance?
-diet, exercise and weight loss
What blood tests would you do to investigate for PCOS?
- testosterone
- SHBG
- LH
- FSH
- prolactin (mildly elevated in PCOS)
- TSH
What would the blood tests typically show in PCOS?
- raised LH
- raised LH to FSH ratio
- raised testosterone
- raised insulin
- normal or raised oestrogen levels
What imaging should be done to diagnose PCOS?
-transvaginal US is the gold standard for visualising the ovaries
-follicles may be arranged around the periphery of the ovary, giving a string of pearls apperance
-diagnostic criteria is:
12 or more developing follicles in one ovary
ovarian volume > 10cm3 ( this can indicate PCOS even without the presence of cysts)
What screening test would be used for diabetes in PCOS?
-2-hour 75g oral glucose tolerance test (OGTT)
What is the general first-line management for PCOS?
management is to first reduce risks of obesity, diabetes, high cholesterol and CVD:
- weight loss
- diet
- exercise
- smoking cessation
- antihypertensive medications if required
- statins if QRISK > 10%
What complications should patients with PCOS be assessed for?
- endometrial hyperplasia or cancer
- infertility
- hirsutism
- acne
- obstructive sleep apnoea
- depression and anxiety
Why is weight loss such a significant part of the management for PCOS?
-weight loss alone can lead to ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and other associated risks
What may be used to help weight loss in women with a BMI above 30?
-Orlistat -> a lipase inhibitor that stops the absorption of fat in the intestines
Why is there a risk of endometrial cancer in PCOS?
- usually the corpus luteum releases progesterone after ovulation
- but as women with PCOS do not ovulate or do so infrequently, they do not produce sufficient progesterone but continue to produce oestrogen without regular menstruation
- this leads to the endometrial lining continuing to proliferate due to the oestrogen without shedding in menstruation
- this results in endometrial hyperplasia with a significant risk of cancer
How is the risk of endometrial cancer investigated in PCOS?
- women with more than 3 month gaps between periods or abnormal bleeding need to have a US to assess endometrial thickness –> cyclical progesterone should be used to induce period before US
- if thickness > 10mm they need to be refered for a biopsy to exclude endometrial hyperplasia or cancer
What are the management options to reduce risk of endometrial cancer in PCOS?
- mirena coil for continuous endometrial protection
- inducing bleed every 3-4 months with either cyclical progestogens or combined OCP
What are the management options to improve infertility in PCOS?
weight loss is the initial step, if fails then:
- clomifene
- laparoscopic ovarian drilling
- IVF
What are the management options to improve hirsutism in PCOS?
- weight loss
- Combines OCP such as co-cyprindiol (dicanette)
- topical elfornithine
- electrolysis
- laser hair removal
- spironolactone
What are the management options to improve acnein PCOS?
combined oral contraceptive pill is first-line for acne in PCOS
