PCOS

Question 1

Diagnosis: 2 out of 3 Rotterdam criteria

Answer 1

1. TVUS appearence of PCO, 12 or more small(2-8 mm) follicles in enlarged(>10 mL) ovary
2. Irregular period(>35 days apart)=oligo/anovulation
3. Clinical/biochemical hirsutism

Question 2

Clinical features

Answer 2

Obesity, acne, hirsutism, oligomenorrhea/amenorrhoea, increased pregnancy complications(eg: miscarriage), anovulatory subfertility, acanthosis nigricans

Question 3

Investigations

Answer 3

1. Bloods: FSH(other causes of anovulation), PRL(prolactinoma), TSH, serum testosterone, LH
2. TVUS: PCO
3. Fasting lipids and glucose

Question 4

Complications

Answer 4

T2DM(up to 50%), 30% develop GDM. Endometrial Cancer. Dyslipidemia leading to hypertension and CV prob. X increased mortality

Question 5

Treatment

Answer 5

1. Diet and exercise.
2. Screen for T2DM(IGT)
   - initial OGTT at Px
   - annual if IGT/FHx/BMI>30/>25 in Asian/Hx of GDM
   - other women: annual fasting glucose, OGTT if >5,6 mmol/L OR OGTT every 2y.
3. CV risk f.
   - consider screening BP, waist circumference, BMI, lipids if >35y
4. Oligomenorrhoea/amenorrhoea
   - progestogen for withdrawal bleed and US for endometrial thickness
   - Normal thickness: COCP/cyclical progestogen/LNG-IUS
5. 3rd gen COCP, X plan conception.(regulate periods and hirsutism)
6. Antiandrogens eg: cyproterone acetate, spironolactone, flutamide, topical eflornithine. Finasteride
7. Metformin
   - only initiated by specialist
8. Sleep apnoea

Question 6

Treatment(Infertility)

Answer 6

Infertility:

1. Diet and exercise(primary care)
2. Clomiphene citrate/+metformin
   - only in secondary care
   - 6 months use
   - risk of multiple pregnancies
   - some experts advise against metformin alone, lower live birth rate.
3. Gonadotrophin and laparoscopic ovarian drilling
   - 3rd line.
   - low-dose step-up regimen with gonadotrophins. US to monitor follicular dev and hCG/recombinant LH injection when about 17 mm. Alternative is continuous SC GnRH pump.
   - decreased risk of multiple pregnancy with laparoscopic ovarian drilling. Risk of periovarian adhesions and ovarian failure.

Question 7

Treatment(Pregnancy)

Answer 7

1. OGTT to screen for GDM and IGT before 20w
2. Avoid metformin, inadequate evidence on safety
3. stop hormonal treatments

Question 8

Side effects of ovulation induction

Answer 8

1. Multiple pregnancies with clomifene/gonadotrophins
2. OHSS
   - w gonadotrophins(rarely clomifene)
   - risk f: <35y, PCO on US
   - ‘short protocol’ reduces rate of OHSS
   - severre cases: ascites, hypovolaemia, thromboembolism, electrolyte disturbance.