PCOS Flashcards
What is the pathophysiology of PCOS?
A) It is an endocrine disorder that is characterized by rapid pulsation of the hypothalamus leading to increased GnRH production => increased FSH/LH => Excess androgen production => Insulin resistance => hyperinsulinemia. This causes 2 things
1) Reduction in sex hormone bindings globulin => increased free testosterone
2) Increased androgen production => repeating the cycle
B) Familial component (50% of 1st degree relatives are affected)
What is the primary presenting complaint usually in PCOS?
Teenager - Acne/hair growth
30+ = struggling to conceive
Define oligomennorhoea
menstruation interval >35 days
Define amenorrhoea
Absence of menses >6 moths
What is the clinical presentation of PCOS?
1) Menstrual irregularities: due to chronic anovulation
=> Oligomenorrhoea: (>35 days)
= > secondary amenorrhoea (>6 months)
2) Subfertility: Due to anovulation
3) Obesity: Due to insulin resistance
4) Hyperandrogenism
=> Acne (on back)
=> Seborrhea (greasy skin)
=> Hirsuitism (male-pattern hair growth)
=> Alopecia (male-pattern hair loss)
What is the difference between virilization and hirsuitism
Virilization also includes breast atrophy, deep voice, and cliteromegaly
This is typically caused by adrenal tumours
State your differentials for PCOS
Hormonal:
Hyperprolactinemia
Thyroid dysfunction
Adrenals:
Cushing’s syndrome
Adrenal tumours
Late onset congenital adrenal hyperplasia
Familial:
Familial hirsutism
How would you diagnose PCOS?
Rotterdam criteria 2/3
1) Clinical evidence of hirsutism + Biochemical: increased androgen index, mild increase in total and free testosterone
2) Oligo/amenorrhoea 2 years after menarche
3) US demonstrating polycystic ovaries (12 follicles 2-9mm, or Ovary >10ml
What exam findings would you expect in PCOS?
Hirsuitism
acne
Obesity!
Acanthosis Nigricans (dark skin under armpits)
What investigations would you perform
First satisfy Rotterdam criteria:
Total free androgen index
Total and free testosterone
Pelvic US for polycystic ovaries
Then Full hormone profile including LH, FSH, Estradiol, Prolactin, TFTs
17-hydroxyprogesterone (for late onset congenital adrenal hyperplasia)
+ Glucose tolerance test (for insulin resistance)
What are the metabolic sequelae of PCOS?
T2DM, obesity, HTN, CVD, Sleep apnoea
What are the Sequelae of PCOS
Main 4:
1) Infertility (increased risk of miscarriage, preterm birth)
2) Endometrial hyperplasia/carcinoma
3) Hyperandrogenism (hirsutism/acne)
4) Metabolic (T2DM, GDM, obesity, HTN, Sleep apnoea, CVD)
Give 2 examples of ovulation induction agents
What are the complications of these agents
Lotrazole and clomiphene citrate
Multiple births
Ovarian hyperstimulation
Ectopic pregnancy
Ovarian torsion
Premature ovarian failure
Give your full management plan for PCOS
1) Infertility
Conservative: Weight loss (restores ovulation in the majority of cases)
Medical: Ovulation induction via Clomiphene Citrate or Lotrazole
GnRH
Surgical: Laparoscopic ovarian diathermy/ovarian drilling
Finally: ART: e.g. IVF
2) Endometrial hyperplasia/carcinoma: Anovulation => no corpus luteum
a) COCP + Metformin
b) LNG-IUS
3) Hyperandrogenism
Hirsuitism => hair removal
Acne: Antibiotics
!Spironolactone: Anti-androgen but needs contraception (teratogenic)
4) Metabolic: (obesity & T2DM)
Conservative: Lifestyle modifications => Dietician referral for diet modification and exercise for weight loss
Medical: Metformin if not givne
Surgical: Bariatric surgery for BMI >35 and nothing else worked
5) Counselling
