PCOS

Question 1

What is PCOS?

Answer 1

affects 5-20% of women of reproductive age

Both hyperinsulinaemia and high levels of LH are seen due to the increase pulse frequency of gonadotrophin releasing hormone

Overlaps with metabolic syndrome

Question 2

What syndrome does PCOS overlap with?

Answer 2

Overlaps with metabolic syndrome

Question 3

What hormone imbalances occur in PCOS?

Answer 3

• Hyperandrogenism
• Insulin resistance *
• Elevated LH and raised Oestrogen
• Insulin:
  -> promotes release of androgens from ovaries and adrenal glands
  -> Suppresses SHBG production by liver which usually binds to androgens reducing their function = more hyperandrogenism
  -> halt development of follicles = anovulation and multiple partially developed follicles = polycystic ovaries

Question 4

What does hyperinsulinism state in PCOS do for androgenism?

Answer 4

• Insulin:
  -> promotes release of androgens from ovaries and adrenal glands
  -> Suppresses SHBG production by liver which usually binds to androgens reducing their function = more hyperandrogenism
  -> halt development of follicles = anovulation and multiple partially developed follicles = polycystic ovaries

Question 5

clinical features of PCOS? (6)

Answer 5

Subfertility + infertility

• Menstrual disturbances
• Hirsutism
• Obesity
• Acanthosis nigricans (insulin resistance)
• Mood changes (depression + anxiety)

Question 6

clinical features of PCOS linked to insulin resistance?

Answer 6

• Acanthosis nigricans (insulin resistance)

Question 7

Investigations for PCOS?

Answer 7

Bedside:
- Investigate for Hirsutism or insulin resistance features

Bloods:
- LH:FSH ratio (increase of >2) to differentiate from menopause which has a normal ratio
- Total testosterone (normal or slightly high)
- Fasting and oral glucose
- TFTs, cortisol, prolactin to exclude

Imaging:
- TVUS: ovarian volume increase and cysts

Question 8

Blood Investigations for PCOS?

Answer 8

Bloods:
- LH:FSH ratio (increase of >2) to differentiate from menopause which has a normal ratio

• Total testosterone (normal or slightly high)
• Fasting and oral glucose
• TFTs, cortisol, prolactin to exclude

Question 9

PCOS LH:FSH ratio?

Answer 9

• LH:FSH ratio (increase of >2) to differentiate from menopause which has a normal ratio

( you get more LH as it is more sensitive to the pulsatile nature of gnRH

Question 10

PCOS testosterone levels?

Answer 10

Total testosterone (normal or slightly high)

Question 11

Which criteria is used for PCOS?

Answer 11

Rotterdam Diagnostic criteria:

Two out of three required for diagnosis:

• Oligo/anovulation
• Clinical/biochemical hyperandrogenism (hirsuitism, acne)
• Polycystic ovaries seen on US (12+ follicles measuring 2-9mm) / increase ovarian volume 10cm3

Question 12

What are the three features in the rotterdam diagnostic criteria for PCOS?

Answer 12

Two out of three required for diagnosis:

• Oligo/anovulation
• Clinical/biochemical hyperandrogenism (hirsuitism, acne)
• Polycystic ovaries seen on US (12+ follicles measuring 2-9mm) / increase ovarian volume 10cm3

Question 13

What polycystic ovary features are needed to be ticked on the rotterdam diagnostic criteria for PCOS?

Answer 13

• Polycystic ovaries seen on US (12+ follicles measuring 2-9mm) / increase ovarian volume 10cm3

Question 14

How to manage PCOS general advice?

Answer 14

Weight reduction

COC pill for fixing cycle

Question 15

How to manage hisutism in PCOS?

Answer 15

COC pill
topical elfornithine

If not planning pregnancy : co-cyprindol
or specialist supervision of : spironolactone, flutamine, finasteride

Question 16

How to manage infertility due to PCOS?

Answer 16

Weight reduction, stimulate ovulation : CLOMIFENE, metformin helps

Question 17

When to use gnRH for PCOS management?

Answer 17

When infertile and clomifene or metforming is not working