PCOS

Question 1

25-year-old female presents with 5-year history of irregular periods, worsening facial hair and infertility. Assess + manage.

Answer 1

Impression
salient features are irregular period, facial hair, infertility; this is indicative of PCOS as a likely cause.

Differentials to consider:

• Congenital adrenal hyperplasia
• Thyroid disease
• Cushings syndrome: can cause hyper-androgenise
• hyperprolactinaemia: can cause amenorrhoea/irregular periods
• Primary amenorrhoea
• unlikely but androgen secreting tumour

Question 2

PCOS - history

Answer 2

History
Sx: obesity, acne, irregular periods, hirsutism, other androgenisation features, infertility, hair loss, high libido, deeper voice, obesity.
- consider differentials with thyroid sx, long term steroid use (cushings),
- RISKS: fam history, age <30, SE Asian, early onset of adrenarche (pubic hair etc)
- Medications: steroids

Question 3

PCOS - Examination

Answer 3

Examination
- general appearance: acne, scalp hair loss, male feature, deep voice, hirsutism, acanthosis nigricans due to reduced insulin sensitivity (metabolic syndrome)

Question 4

PCOS - Investigations

Answer 4

Investigations
Diagnostic:
- serum free and total testosterone (will be elevated)
- Other menstrual cycle hormones (FSH, LH, Estrogen, Prolactin,

Bedside: BSL, 24-hr urinary free cortisol (for cushings)
Bloods: Metabolic screen (lipids, HbA1C, fasting BSL)
Imaging: TV US to check for enlarged ovaries with numerous cysts.

Question 5

PCOS - Management

Answer 5

Management

CVD risk mitigation
non-pharm 
- lifestyle mods (Diet, exercise, weight loss)
- Patient education
- SNAP optimisation
- Psychological support
Pharm
- Metformin

Menstrual irregularity

• COCP (screen for past VTE, migraine + aura, >35, smoking)
• Anti-androgens (Spironolactone)

Hirsuitism
- Topical hair loss treatments

Acne
- topical acne treatments

Infertility/Ovulation induction - 60% will conceive naturally without ovulation induction;

• SERMS (clomiphene: interferes with normal -ve feedback, thereby increasing GnRH and LH and FSH secretion to cause ovulation)
• laparoscopic ovarian drilling
• IVF + MDT referral to fertility clinic