PCOS

Question 1

List the Rotterdam Criteria

Answer 1

1. Oligo or anovulation
2. Hyperandrogenism: acnea, hirsutism, male pattern hair loss, elevated serum androgens
3. Polycystic appearing ovaries: >/= 12 follicles in one or both ovaries or ovarian volume > 10 cc
   * Must have 2 of 3 for diagnosis*

Question 2

List the Adult Treatment Panel III Criteria for metabolic syndrome

Answer 2

Elevated BP (>130/85)
Increased waist circumference (>/= 35 inches)
Elevated fasting glucose levels (>/= 100 mg/dL)
Reduced high-density lipoprotein level (= 50 mg/dL)
Elevated triglyceride levels (>/= 150 mg/dL)

Question 3

List the mechanisms of action of metformin

Answer 3

Increases glucose absorption from GI tract
Increases glucose uptake and utilization (muscle)
Increases peripheral tissue and liver sensitivity to insulin
Increases sex hormone binding globulin
Inhibits hepatic glucose production

Question 4

What is the Ferriman-Gallwey Scale and what score is considered significant?

Answer 4

Scale for hirsutism
Score of 1-4 is given for nine areas of the body
Score <8 normal, 8-15 mild hirsutism, >15 moderate or severe hirsutism

Question 5

What additional medical conditions should you consider/work up in a PCOS patient? Specifically if obese?

Answer 5

Diabetes
Hyperlipidemia
Depression
Obstructive sleep apnea
Endometrial hyperplasia
Non-alcoholic fatty liver disease

Question 6

What is the first line agent for ovulation induction in a PCOS patient? Name its mechanism of action and how to prescribe/dose this medication.

Answer 6

Letrozole
MOA: aromatase inhibitor
Dosing: 2.5 mg PO days 3-7 of cycle, if no ovulation increase to 5 mg next cycle, may go up to 7.5 mg

Question 7

Create a differential diagnosis for PCOS

Answer 7

Pregnancy
Androgen secreting tumor (adrenal or ovarian)
Exogenous androgens
Cushing syndrome
Nonclassical congenital adrenal hyperplasia
Acromegaly
Genetic defects in insulin action
Primary hypothalamic amenorrhea
Primary ovarian failure
Thyroid disease
Prolactin disorders

Question 8

What are the the recommended lifestyle modifications for PCOS patients and impacts on PCOS sequelae?

Answer 8

Dietary change: caloric restriction
Increase in exercise
Reduces diabetes risk and improves metabolic abnormalities comparable to or better than medication
Losing 5-10% of body weight will often result in return of normal ovulation

Question 9

If Clomid/Letrozole fail, what are additional options for treating infertility in a PCOS patient?

Answer 9

Exogenous gonadotropins
Ovarian drilling
IVF

Question 10

What is the mechanism of action of spironolactone for treatment of hirsutism? What is the dosing? What are the side effects?

Answer 10

Mechanisms:
Inhibits ovarian and adrenal steroidogenesis
Competitive inhibitor of androgen receptor at hair follicle
Direct inhibition of 5-a reductase activity
Dosing: 25-100 mg BID, titrated
Side effects: hypotension, increased menstrual frequency, hyperkalemia, SJS, teratogen (ambiguous genitalia)