PCOS Flashcards
Green
What is PCOS?
Polycystic ovarian syndrome comprises hyperandrogenism (e.g. hirsutism), oligomenorrhea and polycystic ovaries on USS in the absence of other causes of polycystic ovaries (e.g. late-onset adrenal hyperplasia, Cushing’s)
It is a diagnosis of exclusion (consider other causes of irregular/absent periods)
What is a polycystic ovary?
Appearance of multiple (>12) small (2-8mm) follicles in an enlarged (>10ml volume) ovary; found in approx. 20% women
What percentage of anovulation is caused by PCOS?
80%
How many women of childbearing age are affected by PCOS?
5-20% (most common endocrine disorders in this group)
What factors are associated with PCOS?
FHx (esp. type 2 diabetes) Obesity Metabolic syndrome (HNT, dyslipidaemia, insulin resistance, visceral obesity) Adverse CVS risk profile with higher prevalence of type 2 diabetes and sleep apnoea1
What does darkened skin on neck and skin flexures suggest?
Acanthosis nigricans - hyperinsulinaemia
What causes PCOS?
True cause unknown
Affected women have disordered LH production and peripheral insulin resistance with compensatory raised insulin levels; raised LH and insulin acting on polycystic ovaries causes inc ovarian androgen production
Raised insulin = inc adrenal androgen production/reduced hepatic production of steroid hormone-binding globulin (increased free androgen levels)
Increased intraovarian androgens - disruption of folliculogenesis = excessively small follicles and irregular/absent ovulation
Raised body weight raises insulin (and so androgen)
What is hirsutism?
Acne and/or excess body hair due to raised peripheral androgens
How is PCO different to PCOS?
PCO patients have enlarged polycystic ovaries without the symptoms of PCOS (obesity, acne, hirsutism, oligo/amenorrhoea)
What is the classical presentation of PCOS?
Oligomenorrhoea +/- hirsutism, acne, subfertility
How is PCOS diagnosed?
Rotterdam criteria (2 out of three must be present:
- Polycystic ovaries (>12 follicles or ovarian volume >10cm3 on USS)
- Oligo/anovulation
- Clinical and/or biochemical signs of hyperandrogenism
What should be considered before PCOS is clinically diagnosed?
Other causes of irregular cycles should be excluded if there is clinical suspicion of
-thyroid dysfunction
-hyperprolactinaemia
-congenital adrenal hyperplasia
-androgen secreting tumours
-Cushing’s syndrome
Remember PCOS is a diagnosis of exclusion
What may be raised in PCOS?
LH raised in 40%
Testosterone raised in 30%
What should be performed to exclude androgen secreting tumours?
Clinically hyperandrogenic
Total testosterone >5nmol/L
Check 17-hydroxyprogesterone
What Ix should be done for PCOS?
Bloods
-FSH (normal in PCOS, raised in ovarian failure, low in hypothalamic disease)
-AMH (high in PCOS, low in ovarian failure)
-Prolactin (exclusion of prolactinoma)
-TSH
-Serum testosterone (for hirsutism; if very high, possibility of androgen-secreting tumour or congenital adrenal hyperplasia)
-LH may be raised (but not diagnostic in PCOS)
USS (check for polycystic ovaries)
Other
-Screen for diabetes and dyslipidaemia (esp in obesity, FHx diabetes, CVS disease)
What are the long-term consequences of PCOS?
Gestational diabetes T2D CVS disease Endometrial cancer esp common in amenorrhoeic women, but reduced if bleeds recommenced (no risk of breast/ovarian cancer) Miscarriage more common after PCOS
Are mortality rates increased in women with PCOS?
Despite number of risk factors (weight, insulin resistance, diabetes, abnormal lipids) morbidity not increased
What are the management options for PCOS?
Lifestyle changes Metformin Clomifene citrate Ovarian drilling COCP Regular withdrawal bleeds Hirsutism treatments
How do lifestyle changes help in PCOS?
Weight loss and exercise increase insulin sensitivity
Smoking cessation advised
Diagnose and treat any underlying HNT, dyslipidaemia and sleep apnoea
How does metformin help in PCOS?
Improves short term insulin sensitivity
May improve menstrual disturbance/ovulatory function
Does not have significant impact on hirsutism/acne (it does not cause weight loss)
Not licensed for use in PCOS so risks and benefits should be fully discussed
How does clomifene citrate help in PCOS?
Induces ovulation (50-60% conceive in first 6m of treatment)
Should only be used in conjunction with fertility Ix, BMI <35 and no more than 6 cycles
Risk of multiple pregnancy and ovarian cancer
Monitor response by USS at least in first cycle
PCOS pts are at inc risk of ovarian hyperstimulation with assisted conception
How does ovarian drilling help with PCOS?
Needlepoint diathermy at 4 points per ovary intending to reduce steroid production
Recommended for those unresponsive to clomifene
65% conceive
No risk of multiple pregnancy, but chance of preterm birth, pre-eclampsia, gestational diabetes and large babies increased
How does the COCP help PCOS?
Control bleeding
Reduce risk of unopposed oestrogen on endometrium (risk of endometrial carcinoma)
How do regular withdrawal bleeds help in PCOS?
If not on pill, recommended 3 monthly e.g. induced with norethisterone 5mg TDS PO 7-10d
Reduce risk of endometrial cancer
How can hirsutism be treated?
Cosmetic treatment
Anti-androgens e.g. cyproterone 2mg/day
Depilatory creams, electrolysis, waxing, shaving and laser help (not NHS funded)
Eflornithine facial cream is anti-androgen, helps with acne
Spironolactone 25-200mg/24h/PO (unlicensed use) also antiandrogenic (but avoid in pregnancy as teratogenic)
