PCOS

Question 1

Define

Answer 1

Rotterdam Criteria for PCOS (≥2 of the following): Affects 1-2 in every 10 women

• Oligo/anovulation (>2 years)
• Clinical or biochemical features of hyperandrogenism
• Polycystic ovaries on USS (>12 in ≥1 ovary measuring 2-9mm OR ≥10cm3 ovarian volume)

· Risk factors – FHx, obesity

Question 2

Signs and symptoms

Answer 2

Hirsutism (upper lips, lower abdomen) Sub-fertility

o Amenorrhoea Weight gain, acne, insulin resistance (acanthosis nigricans)

Question 3

Investigations

Answer 3

TVUSS -> polycystic ovaries (“Pearl Necklace” sign)

• LH: FSH index à >1: 1 (i.e. LH > FSH; 2: 1 or 3: 1)
• Other: testosterone (H), SHBG (L), prolactin (H), TSH (N)

DM monitoring:
- OGTT at diagnosis for…
- BMI ≥25
- Non-Caucasian ethnicity
- Any BMI and >40yo, FHx DM, GDM hx

Annual OGTT for…
- IFG (fasting 6.1-6.9mmol/L)
- IGT (OGTT 7.8-11.1mmol/L)

CVD monitoring (assess risk with QRISK2):
- Lipid profile
- Blood pressure
- Diet, exercise, smoking and weight loss

Question 4

Management

Answer 4

Oligomenorrhoea, amenorrhoea (oligomenorrhoea (≥3m) à refer for TVUSS to assess endometrial thickness)

• Weight reduction
• COCP (indication: contraception and hyperandrogenism)
• Cyclical progesterone (indication: contraception)
• LNG-IUS (indication: contraception)

Hyperandrogenism (Hirsutism and Acne):

• Weight reduction
• 1st line: COCP (indication: contraception and hyperandrogenism)
• Increases SHBG to relieve androgenic symptoms (n.b. co-cyprindiol better)
• Co-cyprindiol (indication: contraception and hyperandrogenism
• Cyproterone acetate and ethinylestradiol
• COCP and enhanced anti-androgenic activity
• Topical eflornithine cream (indication: hyperandrogenism)

Infertility:

1st line: weight loss (if normal weight, go to 2nd line)

2nd line (up to 6 months): clomiphene à clomiphene and metformin (after 3 failed clomiphene cycles)
- Induces ovulation if subfertility is an issue
- Increased risk of multiple pregnancy
- SERM (blocks ER in hypothalamus à reduce -ve feedback à more GnRH pulsatile release)

3rd line: gonadotrophins, IVF (risk: Ovarian Hyperstimulation Syndrome / OHSS)
- OHSS -> multiple luteinized cysts à lots of oestrogen, progesterone, VEGF à pain, bloating

Surgery: laparoscopic ovarian drilling / LOD (destroy ovarian stroma and prompt cycles)

Question 5

Complications

Answer 5

1. Metabolic syndrome (DM and heart disease)
2. Sleep apnoea
3. Cardiovascular disease
4. Endometrial cancer (if >7mm, may be pathological
5. Recommend withdrawal bleed every 3-4 months Subfertility