PCOS Flashcards
how common is PCOS
PCOS is the most frequently encountered endocrinopathy in women of reproductive age. Prevalence is 4-12%
common manifestation of PCOS
characterized by menstrual abnormalities
oligomenorrhea or secondary amenorrhea
if you don’t have this then you don’t have PCOS could have pre diabetes
PCOS usually occurs in this age group
usually manifest around menarche but can happen anytime
Hyperandrogenism effects of PCOS (3 broad systems)
- Clinically manifests as excess terminal body hair in a male distribution (Upper lip, chin, around the nipples and along the linea alba of the lower abdomen)
- Some have acne (typically its cystic acne) or male pattern hair loss
- Occasionally increased muscle mass, deepening of the voice and/or clitoromegaly due to excessive androgens
other than hyperandrogenism, what other symptoms do we see with PCOS
infertility obesity DM sleep apnea acanthosis nigricans metabolic syndrome
why do you see infertility with PCOS
- A subset of women are infertile
2. Most women ovulate intermittently.
what % of PCOS are obese
This is present in nearly half of all women with PCOS
what % of women have DM2 and PCOS
10% of women with PCOS have Type 2 diabetes,
30-40% have impaired glucose tolerance by age 40.
classic dx of PCOS
can be diagnosed clinically in a woman with hirsutism, irregular menstrual cycles and characteristic ovarian morphology.
(Classic ultrasound findings often include multicystic ovaries
(10 or more on each ovary) with the follicle cysts lining the periphery of the ovary)
NIH Dx criteria
defined 2 minimum criteria for diagnosis
- Menstrual irregularities
- Evidence of hyperandrogenism either clinical (hirsutism, acne, male balding) or biochemical (elevated serum androgen level)
- Exclusion of other disorders that can results in menstrual irregularities and hyperandrogenism***
Rotterdam European Society of Human Reproduction/American Society for Reproductive Medicine (ESHRE/ASRM
2003 defined 3 criteria for diagnosis and indicated PCOS maybe present if 2 out of 3 criteria are met:
- Oligoovulation/anovulation
- Clinical or biochemical signs of hyperandrogenism
- Polycystic ovaries
Biochemical abnormalities w/ PCOS
Testosterone levels (3)
may be normal or elevated but usually <200ng/dl.
androstenedione and dehydropiandrosterone sulfate
DHEA-S are usually normal but may be elevated
FSH and LH are normal to high
LH to FSH is usually 3:1 or more
fasting gluscose would be high because of insulin resistance
TSH and prolactin are usually __ in PCOS
normal
need to rule out hypothyroid because can have similar symptoms or pituitary cause
if testosterone is > 150ng need to rule out
Adrenal tumors should be investigated if testosterone is > 150ng/dl. Rule out elevated Cortisol for Cushing’s (run screening ACTH/Cortisol)
rule out cushings by checking
ACTH and cortisol
If suspicious dexamethasone suppression test
Also can test for acromegaly if
no improvement look at IGF1 and growth hormone
can have pituitary tumor
rule out thyroid disorders
order TFTs
rule out Hyperprolactinemia
order prolactin
Late onset Congenital Adrenal Hyperplasia (CAH) can be ruled out with
morning 17-OH progesterone
Ovarian and adrenal tumors should also be considered with
testosterone over 150
pathophys of PCOS
The basic pathophysiologic defect is unknown
Tends to cluster in families thought to be genetic
Abnormal metabolism of androgens and estrogen.–> lower estrogen and higher testosterone
PCOS is associated with peripheral insulin resistance and hyperinsulinemia, obesity amplifies the degree of both.
pathophys –> hormones and PCOS
hyperinsulemia
Increases androgen production from theca cells.
Suppresses hepatic production of sex hormone binding globulin (SHBG).
—> This increases unbound levels of testosterone and free hormone.
Elevated androgen levels also lead to decreased levels of SHBG.
Amplifies the response of the granulosa cell to LH.
because of the decreased FSH relative to LH
can not create estrogen
Because of decreased FSH relative to LH the granulosa cells cannot aromatize androgens to estrogen.
This leads to decreased estrogen levels and consequent anovulation.
goals of PCOS tx
- Restore ovulation
- Decrease the testosterone level
- Improve metabolic disturbances
- Protect uterine lining.
endometrial shedding at least once every three months (if the pt is not on birth control)
progesterone –> gets the lining mature
first line tx for PCOS
First line therapy: Lifestyle modifications
can lower insulin level
- reducing foods that require a lot of insulin
1. Exercise
2. Weight loss (low refined carbohydrate diet).
3. Even a small amount of weight loss can establish menstrual cyclicity.
4. Metabolic abnormalities also improve dramatically with weight loss.
how is BC used to treat PCOS
- Can be used for women not interested in fertility.
- This cyclic withdrawal of estrogen and progesterone leads to complete endometrial shedding and lower LH, therefore lowering androgen levels.
Intermittent Progestin therapy
- Protects uterine lining without estrogen risks.
how do you assess the pt that looks like the could have PCOS
ask about HA to rule out prolactinoma
ask about hypothyroid sxs (constipation, dried skin
look for supraventricular fat pads (cushing’s)
if you have a testosterone level >200 you want to start thinking about
tumors or adrenal issues
LH
responsible for adrogen aspect
what are you ruling out in a pt with PCOS
hyper or hypo thyroid can throw off period
insulin resistance and throw off ovaries
prolactin elevation and a tumor and fuck with cycle
PCOS symptoms but high IgF1 ended up having a pituitary tumor causing acromegaly
this is the velcrow that decreases free floating hormone
Suppresses hepatic production of sex hormone binding globulin (SHBG).
what if OCP fails as tx to produce a period
if birth control is not enough to have a period
will give progesterone for 10 days
Mimics luteal phase
protects the uterine lining
how to treat PCOS in general
reduces metabolic disturbances
improving insulin withh decrease testosterone
metformin can help with this as well as diet and exercise
decreasing foods that require insulin (carbs and sugars)
OCP work by
decrease LH levels and endometrial hyperplasia by restoring menses
estrogen stimulates the production of sex binding hormone
might increase insulin resistance
what birth control should be avoided in PCOS
Avoid Norgestrel or Levonorgestrel
metformin as tx for PCOS
not first line
200 mg of metformin is hte max for DM but can go up to 250mg for PCOS
how does spironolactone work for PCOS
blocks testosterone receptors
this teatrogenic and must be used with OCP
clomid for PCOS
usually given for infertility
clomiphene
could increase the risk of varian cancer?
typical fasting insulin
10
nml free testosterone
1-21
DHEA
dehydroepiandrosterone. It is a weak male hormone (androgen) produced by the adrenal glands in both men and women
Ages 18 to 19: 145 to 395 micrograms per deciliter (µg/dL)
17OH-progesterone
to rule out nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency
why would you have an MRI for a pt with PCOS
pituitary adenoma suspected
