PCOS

Question 1

What criteria define polycystic ovaries on ultrasound?

Answer 1

More than 12 follicles (2-9 mm) OR ovarian volume > 10 mL in either ovary

Question 2

Your patient has irregular periods. What two further questions can you ask to assess whether her bleeding is ovulatory or anovulatory?

Answer 2

Presence of premenstrual molimina
Presence of dysmenorrhea
(Both are typically absent with anovulatory bleeding)

Question 3

True or false: clitoromegaly is a sign of hyperandrogenism that may be seen in PCOS.

Answer 3

False - clitoromegaly is a sign of virilization and should prompt investigation for androgen-secreting tumours

Question 4

List five blood tests you would consider for a patient suspected to have PCOS.

Answer 4

Total testosterone
TSH
PRL
17-OHP
DHEAS - somewhat controversial, may not be necessary unless patient is severely virilized
LH - although not necessary for diagnosis, LH:FSH > 2 supports the diagnosis of PCOS
OGTT/HbA1C

Question 5

What is the mechanism by which OCPs improve hyperandrogenism in PCOS?

Answer 5

Negative feedback to hypothalamus & pituitary - decreased LH, decreased ovarian androgen production
Estrogen increases SHBG, therefore free androgens are decreased
Some pills have anti-androgenic progestins

Question 6

What medical therapies are available to women with PCOS who do not desire pregnancy, yet want to avoid OCPs?

Answer 6

Cyclic progesterone
Anti-androgens (spironolactone, finasteride)
Cosmetic therapy

Question 7

What is the first-line treatment for women with PCOS who want to conceive?

Answer 7

Historically, clomiphene citrate
Recently, letrozole shown to be superior for ovulation induction
Adding metformin improves ovulatory response