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Zero to finals Gynaecology Marina > PCOS > Flashcards

PCOS Flashcards

1
Q

What is PCOS?

A

-PCOS is a common condition causing metabolic and reproductive problems in women

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2
Q

What are key characteristic features of PCOS?

A
  • multiple ovarian cysts
  • infertility
  • oligomenorrhoea
  • hyperandrogenism
  • insulin resistance
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3
Q

What does anovulation refer to?

A

absence of ovulation

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4
Q

What does oligoovulation refer to?

A

irregular, infrequent ovulation

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5
Q

What does amenorrhoea refer to?

A

absence of menstrual periods

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6
Q

What does oligomenorrhoea refer to?

A

irregular, infrequent periods

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7
Q

What are androgens?

A

male sex hormones such as testosterone

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8
Q

What does hyperandrogenism refer to?

A

effects of high levels of androgens

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9
Q

What does hirsutism refer to?

A

growth of thick dark hair, often in a male pattern, e,g male pattern facial hair

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10
Q

What is the Rotterdam criteria?

A

-Rotterdam criteria is used to make a diagnosis of PCOS with diagnosis requiring at least 2/3 features

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11
Q

What are the features of the Rotterdam criteria?

A
  • oligoovulation or anovulation presenting with irregular periods
  • hyperandrogenism, charecterised by hirsutism and acne
  • polycystic ovaries on US
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12
Q

What are the key features in presentation of PCOS?

A
  • oligo/amenorrhoea
  • infertility
  • obesity (70% of pts)
  • hirsutism
  • acne
  • male pattern baldness
    -Mood swings/depression/anxiety
    -Acanthosis nigricans (secondary to insulin resistance)
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13
Q

What are other features of PCOS?

A
  • Insulin resistance and diabetes
  • Acanthosis nigricans
  • Cardiovascular disease
  • Hypercholesterolaemia
  • Endometrial hyperplasia and cancer
  • Obstructive sleep apnoea
  • Depression and anxiety
  • Sexual problems
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14
Q

What is acanthosis nigricans?

A
  • thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture.
  • It occurs with insulin resistance.
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15
Q

It is important to rule out other causes of hirsutism, what are they?

A
  • medications such as phenytoin, ciclosporin, corticosteroids, testosterine and anabolic steroids
  • ovarian or adrenal tumours that secrete androgens
  • Cushing’s syndrome
  • Congenital adrenal hyperplasia
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16
Q

How does insulin resistance further promote hyperandrogenism in PCOS?

A
  • 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
17
Q

What can help reduce insulin resistance?

A

-diet, exercise and weight loss

18
Q

What blood tests would you do to investigate for PCOS?

A
  • testosterone
  • SHBG
  • LH
  • FSH
  • prolactin (mildly elevated in PCOS)
  • TSH
19
Q

What would the blood tests typically show in PCOS?

A
  • raised LH
  • raised LH to FSH ratio
  • raised testosterone
  • raised insulin
  • normal or raised oestrogen levels
20
Q

what biochemical investigations can be done to include PCOS (& exclude other pathologies):

A
  1. LH:FSH ratio: Increased (>2). This is also helpful in excluding menopause where the ratio is normal.
  2. Total testosterone: normal/slightly raised
  3. Fasting and oral glucose tolerance tests: helps diagnose insulin resistance.

Other tests that might be indicated if other pathologies are suspected include:
1. TFTs (thyroid dysfunction)
2. 17-hydroxyprogesterone levels (CAH)
3. Prolactin (hyperprolactinaemia)
4. DHEA-S and free androgen index (androgen secreting tumours)
5. 24-hour urinary cortisol (Cushing’s syndrome)

Imaging:

Transabdominal and transvaginal ultrasound: Shows increased ovarian volume and multiple cysts.

21
Q

What imaging should be done to diagnose PCOS?

A

-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)

22
Q

What screening test would be used for diabetes in PCOS?

A

-2-hour 75g oral glucose tolerance test (OGTT)

23
Q

What is the general first-line management for PCOS?

A

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%
24
Q

What complications should patients with PCOS be assessed for?

A
  • endometrial hyperplasia or cancer
  • infertility
  • hirsutism
  • acne
  • obstructive sleep apnoea
  • depression and anxiety
25
Q

Why is weight loss such a significant part of the management for PCOS?

A

-weight loss alone can lead to ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and other associated risks

26
Q

What may be used to help weight loss in women with a BMI above 30?

A

-Orlistat -> a lipase inhibitor that stops the absorption of fat in the intestines

27
Q

Why is there a risk of endometrial cancer in PCOS?

A
  • 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
28
Q

How is the risk of endometrial cancer investigated in PCOS?

A
  • 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
29
Q

What are the management options to reduce risk of endometrial cancer in PCOS?

A
  • mirena coil for continuous endometrial protection

- inducing bleed every 3-4 months with either cyclical progestogens or combined OCP

30
Q

What are the management options to improve infertility in PCOS?

A

weight loss is the initial step, if fails then:

  • clomifene
  • laparoscopic ovarian drilling
  • IVF
31
Q

What are the management options to improve hirsutism in PCOS?

A
  • weight loss
  • Combines OCP such as co-cyprindiol (dicanette)
  • topical elfornithine
  • electrolysis
  • laser hair removal
  • spironolactone
32
Q

What are the management options to improve acnein PCOS?

A

combined oral contraceptive pill is first-line for acne in PCOS

33
Q

A 22-year-old woman attends her GP complaining her periods have become irregular over the past 2 years, often taking her by surprise, as there is often several months between each one. Prior to this, she had a regular 30-day cycle. She also reports some weight gain over the same period and thinning of her hair. On examination, it is noted that she has widespread acne, and the hair on the lateral third of each eyebrow is significantly thinned. Which of the following investigations will identify the most likely diagnosis?

A. Luteinising hormone (LH) and follicle-stimulating hormone (FSH) tests
B. TVUSS
C. Urine pregnancy test
D. Genetic karyotyping
E. TFTs

A

E. TFTs

The most likely diagnosis here is hypothyroidism. While there is a range of differentials here, hypothyroidism can explain all of these symptoms, except for acne. Loss of the lateral third of the eyebrow is known as the sign of Hertoghe, and it can only be explained by hypothyroidism (or dermatitis atopica or leprosy, but these are unlikely here), whereas acne is a common finding in this age group.

34
Q

A 24-year-old woman presents to her GP with infrequent periods, having only 7 periods last year, and none in the last 6 months. She also complains of bad acne, and having to shave her face.

Which of the following would be consistent with the most likely diagnosis?

A. Low LH

B. Normal FSH

C. High sex hormone-binding globulin

D. Low free androgen index

E. Low total testosterone

A

B. Normal FSH

This is the correct answer. The oligomenorrhoea and clinical signs of hyperandrogenism make polycystic ovary syndrome the most likely diagnosis. Patients with PCOS usually present with an elevated (>2) LH:FSH ratio, usually where FSH is low/normal and LH is raised. However, there are inconsistencies with the ratio dependent on the menstrual cycle.

Not A: Low LH:

LH may be raised in PCOS, while the FSH levels remain normal

Not D: Low free androgen index

The free androgen index is calculated by 100 times total testosterone divided by sex hormone-binding globulin. If the testosterone is raised and sex hormone-binding globulin low, then the free androgen index is high

Not E: Low total testosterone

Total testosterone can be normal or raised in polycystic ovary syndrome

35
Q

Pharmacological treatment for women not planning pregnancy:

A
  1. Co-cyprindrol - Useful for reducing hirsutism and inducing regular menstruation.
  2. Combined oral contraceptive pill (COCP) - used to reduce irregular bleeding and protects against endometrial cancer.
  3. Metformin - Helps with menstrual regularity, hirsutism and acne.
36
Q

Pharmacological treatment for women wishing to conceive:

A
  1. Clomiphene - Induces ovulation and improves conception rates.
  2. Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy.
  3. Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary.
    Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed.

Zero to finals Gynaecology Marina (24 decks)

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