PCOS

Question 1

What is the most common cause of infertility in women?

Answer 1

PCOS

Question 2

What is happening pathophysiology-wise in PCOS?

Answer 2

LH:FSH ratio is out of whack

>2

Question 3

Which hormone oversensitivity secretion is occurring in PCOS?

Answer 3

DHEA-S
TESTOSTERONE
Androstenedione

Question 4

What are the four pillars of PCOS pathophysiology which explain the visualized S/Sx?

Answer 4

Hypothalamic-Pituitary abnormalities (LH:FSH >2)

Hyperandrogenism

Estrogen abnormalities (tonic prod. of estradiol)

Insulin resistance

Question 5

How do elevated levels of insulin interact with PCOS females leading to increased androgen secretion?

Answer 5

Insulin stimulates androgen production by thecal cells of the ovaries in PCOS women

Question 6

What are the high risk groups for PCOS?

Answer 6

Oligo-ovulatory infertility
Obesity +/- insulin resistance
Diabetes (Type 1, 2, GDM)
Relatives w/ PCOS

Question 7

What S/Sx should raise your suspicion of PCOS?

Answer 7

Amenorrhea

Menstrual irregularities

Androgen excess

Question 8

T/F

A definitive Dx can be made of PCOS with an U/S with multiple cysts visible on the ovaries.

Answer 8

FALSE

U/S IS NOT SUFFICIENT ENOUGH TO MAKE Dx YOU NEED MORE TO PROVE THE METABOLIC / ANDROGEN IMBALANCE

Question 9

What is the typical presentation of an individual with PCOS?

Answer 9

Sleep apnea
Nonalcoholic steatohepatitis (NASH)
Dyslipidemia (

Question 10

What are the NIH criteria for PCOS?

Answer 10

Menstrual irregularity

Clinical or biochemical evidence of hyperandrogenism

R/o other causes of menstrual irregularity
~~Congen. adrenal hyperplasia
~~Androgen secreting tumors
~~Hyperprolactinemia

Question 11

What are the Rotterdam Criteria for Dx?

Answer 11

Need 2 of the following
~~Polycystic ovaries
~~Ovulatory dysfunction
~~Evidence of androgen XS

Question 12

What is the diagnostic criteria for PCOS in adolescents?

Answer 12

Abnormal uterine bleeding pattern

Hyperandrogenism (above adult normal range w/ severe acne)

Question 13

How can you evaluate menstrual irregularity?

Answer 13

<9 menses / yr
Anovulatory cycles
Testing –> TSH, hCG, LH/FSH (to r/o ovarian failure), Prolactin

Question 14

What lab values would you order and look at for the hyperandrogenism aspect of PCOS?

Answer 14

ELEVATED FREE TESTOSTERONE
~~Most sensitive test~~

DHEA-S +/- androstenedione to r/o adrenal origin

Question 15

Your PT w/ suspected PCOS has been referred to you with sets of labs already ordered. The results are in; what would you expect to see on Lipid panel and glucose if the PT is + PCOS?

Answer 15

Dyslipidemia:  (FASTING LIPIDS)
       High LDL
       High Triglycerides
       Low HDL
Glucose intolerance

Question 16

What should your differential for PCOS include / rule out?

Answer 16

Congenital Adrenal Hyperplasia
21-hydroxylase deficiency

Cushing’s Syndrome

Virilizing tumors, anabolic steroids

Question 17

How would you rule out Acquired Congenital Adrenal Hyperplasia if higher on your differential?

Answer 17

Blood 17-hydroxyprogesterone
>200 ng/dL suggestive
Confirm w/ ACTH

Question 18

What are the therapeutic goals for PCOS patients when managing their care?

Answer 18

Reduce serum androgens

Improve reproduction function

Lower the risk of insulin related complications

Promote weight loss (diet and exercise)

Question 19

What is the primary drug therapy for PCOS PTs?

Answer 19

Oral Contraceptives!
~~Increases sex hormone binding globulin
~~Decreases androgen

Oral contraceptives w/ progestin and reduced androgens (i.e. YAZ)

Antiandrogens –> Spironolactone (6months to visualize effect

Question 20

If fertility is an important concern of PTs; what therapy should you prescribe your PCOS PT?

Answer 20

Weight Loss is massively important

Clomiphene

Metformin (off label) reduces testoterone
TZD (off label) reduces Testosterone

Question 21

How do Metformin and TZD individually contribute to glucose control as well?

Answer 21

Metformin 500mg BID –> Suppress hepatic glucose output (also provides endometrial protection)

TZDs –> Improves glucose uptake

Question 22

What are some long-term consequences of PCOS which must be considered and managed with PTs w/ PCOS?

Answer 22

Endometrial / Ovarian CA

Diabetes

CAD (2 to 5x risk)