PCOS

Question 1

What is polycystic ovarian syndrome?

Answer 1

Hyperandrogenism
Oligomenorrhoea
Polycystic ovaries on US
In absence of other causes of polycystic ovaries (later-onset adrenal hyperplasia, Cushing’s)

Question 2

What hormonal changes are seen in PCOS?

Answer 2

Hyperinsulinaemia

High LH

Question 3

How does PCOS present?

Answer 3

Oligomenorrhoea
Hirsutism, acne (due to hyperandrogenism)
Subfertility

Obesity
Acanthosis nigrcans on neck and skin flexures due to hyperinsulinaemia

Associated with metabolic syndrome (HTN. dyslipidaemia, insulin resistance, visceral obesity)

Question 4

What investigations for PCOS?

Answer 4

Pelvic US - multiple cysts on the ovaries
FSH, LH, Prolactin, TSH, testosterone:
Raised LH:FSH ratio
Prolactin may be normal or mildly elevated
Testosterone may be normal or mildly elevated - if very high consider androgen excreting tumour
Check for impaired glucose tolerace

Question 5

How is PCOS diagnosed?

Answer 5

Rotterdam criteria (2/3 must be present):
Polycystic ovaries (12 or more follicles or ovarian volume >10cm3 on US)
Oligo-ovulation or anovulation
Clinical and/or biochemical signs of hyperandrogegism

Exclude:
Thyroid dysfucntion
Hyperprolactinaemia
CAH
Androgen secreting tumours
Cushing's syndrome

Question 6

What is management for PCOS generally?

Answer 6

Weight loss and exercise in order to increase insulin sensitivity
Smoking cessation
Treat diabetes, HTN, dyslipidaemia and sleep apnoea
COCP may help regulate cycle and induce monthly bleed and reduce risk of unopposed oestrogen on the endometrium
If not on pill, regular withdrawal bleeds e.g. 3 monthly induced with norethisterone in those in whom oestrogen use is not wanted or CI
Metformin

Question 7

What is management for hirsutism in PCOS?

Answer 7

Cosmetically
COCP with Anti-androgen: co–cyprindiol
Eflotnithine facial cream is anti-androgen
Spironolactone is antiadrogenic but teratogenic so avoid in pregnancy

Question 8

What is management for infertility?

Answer 8

Metformin improves insulin sensitivity in the short term and may improve menstrual disturbance and ovulatory function
Clomifene citrate (anti-oestrogen) induces ovulation
- used in conjunction with fertility investigation in women BMI<35 and for no more than 6 cycles.
Warn of risk of multiple pregnancy and ovarian cancer

Ovarian drillin (needlepoint diathermy in 4 places per ovary with the intent of reducing steroid proaction) for those nor responding to clomifene.

Question 9

How does clomifene work? Risk?

Answer 9

Anti-Oestrogen
Occupies hypothalamic oestrogen receptors without activating
This interferes with binding of oestradiol and prevents negative feedback inhibition of FSH secretion

Risk of multiple pregnancy and ovarian cancer

Question 10

What are long-term consequences of PCOS?

Answer 10

Gestational diabetes (screen at 24-28 weeks)
T2DM (screen if overweight o other risk factors)
Cardiovascular disease
Endometrial dance (3-4 monthly withdrawal bleeds reduces risk)