PCOS

Question 1

Rotterdam criteria for PCOS

Answer 1

2 out of 3 required for dx
1. Clinical or biochemical hyperandrogenism
2. Anovulation
3. Polycystic ovarian morphology

Question 2

NIH criteria for PCOS

Answer 2

Need both…
1. Clinical or biochemical hyperandrogenism
2. Anovulation

Question 3

Hyperinsulinemia has what affect on androgens?

Answer 3

Compensatory hyperinsulinemia results in decreased sex-hormone binding globulin –> thus more circulating androgens

Question 4

Two pregnancy complications assc with PCOS

Answer 4

1. GDM
2. Hypertensive disorders

Question 5

Long term health complications assc with PCOS

5

Answer 5

1. Metabolic syndrome: T2DM
2. NA fatty liver
3. Sleep apnea
4. Endometrial cancer
5. Depression

Question 6

Suggested eval for PCOS: physical

Answer 6

Question 7

Suggested eval for PCOS: laboratory

3

Answer 7

1. Hyperandrogenism: total T and SHBG
2. Exclude other causes: TSH, PRL, 17-hydroxyprogesterone, cortisol lvl
3. Metabolic: 2hr GTT, lipid panel

Question 8

Suggested eval for PCOS: US

Answer 8

One or both ovaries
– 12+ follicles measuring 2-9mm in diameter
– inc ovarian volume, 10cm3
Look for endometrial anomalies

Question 9

Dx of metabolic syndrome

5

Answer 9

1. Waist circumference >35 in
2. BP >130/85
3. FBG >100
4. HDL <50
5. Trig’s >150

Question 10

Are women on COC with PCOS at higher risk for CV events?

Answer 10

there is no evidence that women with PCOS are at greater risk for either metabolic adverse effects or cardiovascular complications of COCs

Question 11

____ is a potential alternative to restore menstrual cyclicity. Ability to protect endometrium less well established, so second line.

Answer 11

Metformin is a potential alternative to restore menstrual cyclicity as it restores ovulatory menses in approximately 30 to 50 percent of women with PCOS. Its ability to provide endometrial protection is less well established, and we therefore consider it to be second-line therapy

if using, order luteal phase progesterone to see if ovulation has happened

Question 12

Med to control hirsutism

Answer 12

1. COC- 1st line.
2. Spironolactone- add after 6mo if COC not enough

What about metformin? assc with minimal or no benefit and less effective than 2 meds above

Question 13

Things to consider with spironolactone (2)
Starting dose?

Answer 13

1. teratogen- can cause feminization of male fetus. use only with reliable contraception
2. does not regulate menses alone

DOSE- start with 50-100mg BID

Question 14

Lower androgenicity progestins (3)
Thoughts about these?

Answer 14

1. desogestrel
2. dienogest
3. drospirenone
4. norgestimate (no 20mcg option)

NOTE- higher risk of VTE

Question 15

what is the COC of choice to start PCOS pt on?

Answer 15

20mcg ethinyl estradiol pill with norethindrone

Question 16

ovulation induction meds for PCOS

Answer 16

1. letrozole- 1st line, but not FDA approved
2. clomid- live birth rate lower
3. metformin- less effective than both above as monotherapy. data limited as ovulation induction agent

Question 17

does acupuncture during IVF improve fertility in PCOS pt?

Answer 17

The addition of acupuncture during IVF cycles does not improve outcomes

Question 18

what about ovarian drilling for infertility in PCOS?

Answer 18

2nd line when clomid/letrozole doesn’t work. ovarian drilling has similar efficacy but results in lower risk of high order multiple gestations or OHSS

RISK- adhesion formation