PCOS

Question 1

What is the aetiology of PCOS?

Answer 1

environmental (toxins, diet, nutrition), epigenetic (DNA methylation etc) and genetic factors (genes of HPG axis pathway, fat mass and obesity gene etc)

Question 2

What are associated comorbidities with PCOS?

Answer 2

Non-alcoholic fatty liver
Depression/anxiety
Obesity/metabolic syndrome
Infertility
Obstructive sleep apnea
Endometrial cancer
CVD
Impaired glucose tolerance

Question 3

What is the diagnostic criteria for PCOS?

Answer 3

Rotterdam criteria requiring 2/3:

Infrequent or no ovulation (amenorrhoea/oligmenorrhoea)

Clinical (hirsuitism, acne, male pattern alopecia) or biochemical signs of hyper-androgenism (elevated levels of total or free testosterone/androgen)

Polycystic ovaries on USS: the presence of 12 or more follicles in one or both ovaries +/- increased ovarian volume (>10ml)

Question 4

What are clinical features of PCOS?

Answer 4

Menstrual irregularity
Hyperandrogenism - acne, hirsutism, alopecia
Polycystic ovaries
Obesity/overweight

Question 5

What is the management of PCOS?

Answer 5

Lifestyle - exercise, smoking cessation, diet
Hyperandrogenism - anti-androgen +/- inositol
Metabolic - metformin
Psychological support
Infertility - letrazole, metformin, clomiphene

Question 6

What is the management of oligomenorrhoea in PCOS? Why?

Answer 6

Cyclical progestogens
COCP
Mirena IUS

Treatment to prevent endometrial hyperplasia and later carcinoma

Question 7

What is treatment of hirsutism?

Answer 7

COCP
Finasteride - 5alpha reductase inhibitor
Spironolactone - aldosterone and androgen receptor antagonist
Cyproterone acetate
Flutamide - androgen receptor antagonist
Eflornithine - limits cell division and function in pilosebaceous unit

Mechanical - shaving, plucking, waxing

Question 8

What is treatment of anovulatory infertility?

Answer 8

Weight loss if BMI >30
Aromatase inhibitors: letrozole ovulation induction
Clomiphene citrate
Gonadotrophins
Ovarian drilling - destroy ovarian and androgen producing tissue

Question 9

How does letrazole work?

Answer 9

block oestrogen biosynthesis and reduce negative feedback at pituitary

Question 10

How does clomiphene citrate work?

Answer 10

inhibits oestrogen receptors at hypothalamus inhibiting negative feedback of oestrogen on gonadotrophin release leading to up regulation of hypothalamic-pituitary-gonadal axis

Question 11

What is treatment of endocrine symptoms of PCOS?

Answer 11

Metformin - improves insulin sensitivity, promotes weight loss, regulates ovulation