PCOS

Question 1

What is PCOS?

Answer 1

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)

Question 2

What is a polycystic ovary?

Answer 2

Appearance of multiple (>12) small (2-8mm) follicles in an enlarged (>10ml volume) ovary; found in approx. 20% women

Question 3

What percentage of anovulation is caused by PCOS?

Answer 3

80%

Question 4

How many women of childbearing age are affected by PCOS?

Answer 4

5-20% (most common endocrine disorders in this group)

Question 5

What factors are associated with PCOS?

Answer 5

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

Question 6

What does darkened skin on neck and skin flexures suggest?

Answer 6

Acanthosis nigricans - hyperinsulinaemia

Question 7

What causes PCOS?

Answer 7

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)

Question 8

What is hirsutism?

Answer 8

Acne and/or excess body hair due to raised peripheral androgens

Question 9

How is PCO different to PCOS?

Answer 9

PCO patients have enlarged polycystic ovaries without the symptoms of PCOS (obesity, acne, hirsutism, oligo/amenorrhoea)

Question 10

What is the classical presentation of PCOS?

Answer 10

Oligomenorrhoea +/- hirsutism, acne, subfertility

Question 11

How is PCOS diagnosed?

Answer 11

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

Question 12

What should be considered before PCOS is clinically diagnosed?

Answer 12

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

Question 13

What may be raised in PCOS?

Answer 13

LH raised in 40%

Testosterone raised in 30%

Question 14

What should be performed to exclude androgen secreting tumours?

Answer 14

Clinically hyperandrogenic
Total testosterone >5nmol/L
Check 17-hydroxyprogesterone

Question 15

What Ix should be done for PCOS?

Answer 15

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)

Question 16

What are the long-term consequences of PCOS?

Answer 16

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

Question 17

Are mortality rates increased in women with PCOS?

Answer 17

Despite number of risk factors (weight, insulin resistance, diabetes, abnormal lipids) morbidity not increased

Question 18

What are the management options for PCOS?

Answer 18

Lifestyle changes
Metformin
Clomifene citrate
Ovarian drilling
COCP
Regular withdrawal bleeds
Hirsutism treatments

Question 19

How do lifestyle changes help in PCOS?

Answer 19

Weight loss and exercise increase insulin sensitivity
Smoking cessation advised
Diagnose and treat any underlying HNT, dyslipidaemia and sleep apnoea

Question 20

How does metformin help in PCOS?

Answer 20

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

Question 21

How does clomifene citrate help in PCOS?

Answer 21

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

Question 22

How does ovarian drilling help with PCOS?

Answer 22

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

Question 23

How does the COCP help PCOS?

Answer 23

Control bleeding

Reduce risk of unopposed oestrogen on endometrium (risk of endometrial carcinoma)

Question 24

How do regular withdrawal bleeds help in PCOS?

Answer 24

If not on pill, recommended 3 monthly e.g. induced with norethisterone 5mg TDS PO 7-10d
Reduce risk of endometrial cancer

Question 25

How can hirsutism be treated?

Answer 25

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)