PCOS

Question 1

Rotterdam Criteria

Answer 1

2 of 3 criteris required
1. Oligomenorrhoea or anovulation
2. Clinical or biochemical signs of hyperandrogenism ie
- Hirsutism/acne
- Raised Testosterone and FAI
3. Polycystic ovaries on ultrasound: >/= 12 follicles of 2-9mm diameter with total ovarian volume >/= 10ml

ISUOG>/= 25 follicles

Question 2

Differential diagnoses to exlude

Answer 2

• Late onset CAH
• Cushings
• Androgen secreting tumour
• Hypothyroidism
• Hyperprolactinaemia
• Acromegaly

Question 3

NB History to note

Answer 3

• History
• Symptoms of hyperandrogenism (acne, hirsuitism, male pattern baldness)
• Medical hx
  noting :Obesity, Hypertension, Dyslipidaemia
• Menstrual hxnoting Oligo/amenorrhea
• Obstetric hx noting history of Infertility, Plans for conception
• Family hx noting history of PCOS

Question 4

NB Examination findings

Answer 4

o BMI, waist:hip ratio
o Blood pressure
o Acanthosis nigracans (marker of insulin resistence)
o Hirsutism assessment using Ferriman Gallway
o Abdominal palpation
o Spec/bimanual examination to exclude other causes of menstrual or endocrine disturbance

Question 5

Investigations to perform

Answer 5

Bloods
§ To confirm diagnosis
* Free testosterone (Ý), free androgen index (Ý), SHBG (ß)
* Elevated LH (particularly LH:FSH ratio)
§ To exclude other causes
* Serum bhCG
* Serum FSH/oestradiol to exclude hypo/ergonadotrophic hypogonadism/POI
* Prolactin, TSH, 24 hour urine cortisol
* 17-OH progesterone (CAH)
* DHEAS (adrenal tumour)
§ To screen for complications
* Fasting oral GTT* Fasting lipids
* Consider endometrial sample
o Transvaginal pelvic ultrasound
§ Confirm follicle count
§ Exclude ovarian mass
§ Endometrial thickness

Question 6

Management

Answer 6

Goals: Focus on individual issues and prevent longterm complications* Manage symptoms
o Hirsuitism
§ Cosmetic hair removal
§ Spironolactone
* Diuretic with anti-androgen effects
§ Cyproterone acetate
* Anti-androgen progesterone
* Monitor for and treat long-term consequences
o Weight reduction (dietician, exercise, bariatric surgery)
o 2-yearly screening for metabolic syndrome
* Fertility
o Weight reduction: 5% weight loss can improve fertility significantly by
increasing ovulation rate
o Ovulation induction
§ Do not give if BMI >35
§ Clomiphene
* Anti-oestrogen
* Inhibits negative feedback to increase GnRH pulsatility
* 10% chance twins
OR Letrozole : Aromatase inhibitor
§ Metformin
* Insulin sensitising agent
* Second line after clomid
* Commence at 500mg bd and increase to 1g bd
* 8% conception rate
§ Gondadotrophin therapy (FSH injections then trigger)
* 10% conception rate/cycle, 25% chance twins
* PCOS high risk of OHSS
§ Laparoscopic ovarian drilling
* 60% conception rate (80% ovulate)
* Decreased risk of multiples cw gonadotrophins* Protect endometrium (if not desiring fertility)
o Combined OCP
§ Avoid androgenic progesterones
§ Desogestrel (Marvelon), drosperinone (Yasmin) and cyproterone
(Dianne) preferred
o Oral progesterone or Mirena also acceptable