PCOS

Question 1

Define PCOS

Answer 1

Polycystic ovary syndrome (PCOS) is a heterogeneous condition within the endocrine system, with its onset commonly observed at puberty. The disorder is characterised by hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.

Question 2

Describe epidemiology of PCOS

Answer 2

Prevalent, affecting up to a third of women during their reproductive years.

Question 3

What hormone imbalances cause PCOS?

Answer 3

hyperandrogenism, insulin resistance, elevated levels of luteinizing hormone (LH) and raised oestrogen levels.

Question 4

What are symptoms of PCOS?

Answer 4

Oligomenorrhoea
Subfertility
Acne
Hirsuitism
Obesity
Mood changes including depression and anxiety
Male pattern baldness
Acanthosis nigricans (secondary to insulin resistance)

Question 5

What are differentials of PCOS?

Answer 5

Menopause: characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.
Congenital adrenal hyperplasia (CAH): presenting with signs of androgen excess like hirsutism, acne, and irregular periods.
Hyperprolactinaemia: symptoms include irregular periods, galactorrhoea, and infertility.
Androgen-secreting tumours: may cause virilisation, amenorrhoea, and hirsutism.
Cushing’s syndrome: characterised by weight gain, purple stretch marks, and easy bruising.

Question 6

What biochemical investigations are used?

Answer 6

LH:FSH ratio: An increase (>2) aids in differentiating from menopause where the ratio is normal.

Total testosterone: May be normal or slightly elevated.

Fasting and oral glucose tolerance tests: Used to diagnose insulin resistance.

Other tests may include TFTs (for thyroid dysfunction), 17-hydroxyprogesterone levels (for CAH), prolactin (for hyperprolactinaemia), DHEA-S and free androgen index (for androgen-secreting tumours), and 24-hour urinary cortisol (for Cushing’s syndrome).

Question 7

What are imaging investigations for PCOS

Answer 7

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

Question 8

What is the Rotterdam Diagnostic Criteria?

Answer 8

PCOS diagnosed if 2/3 criteria met:

Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism

Question 9

What is the management of PCOS?

Answer 9

General advice:
Encouragement of weight loss and exercise
Education on increased risks of cardiovascular disease, diabetes, and endometrial cancer

Pharmacological:
Co-cyprindrol: Reduces hirsutism and promotes regular menstruation.
Combined oral contraceptive pill (COCP): Decreases irregular bleeding and offers protection against endometrial cancer.
Metformin: Aids in regularising menstruation, reducing hirsutism, and acne.

Pharmacological if TTC:
Clomiphene: Induces ovulation and enhances conception rates.
Metformin: Can be used alone or in combination with clomiphene to improve chances of pregnancy.
Ovarian drilling: A second-line laparoscopic surgical procedure that damages the hormone-producing cells of the ovary.
Gonadotrophins: Utilised to induce ovulation if clomiphene and metformin prove ineffective.