PCOS and Endometriosis Flashcards
What is PCOS?
Polycystic ovary syndrome (PCOS) includes symptoms of hyper-androgenism, presence of hyper-androgenaemia, oligo-/anovulation, and polycystic ovarian morphology on ultrasound.
• Most common endocrinopathy in women of reproductive age.
Which conditions is PCOS associated with?
Associated with insulin resistance, metabolic syndrome, non-alcoholic fatty liver disease, and increased risk of developing type 2 diabetes.
What is the cause of PCOS?
- Aetiology is unknown.
- It is a syndrome wherein multiple systems are affected and the site of the primary defect is unclear.
- Most PCOS depends on genetic factors.
Hx and exam for PCOS
- Presence of risk factors such as premature adrenarche or a family hx of PCOS.
- Female of reproductive age
- Irregular menstruation
- Infertility
- Hirsutism
- Acne
- Overweight/ obesity
- HTN
Investigations for PCOS?
- Serum 17-hydroxyprogesterone
- Serum prolactin (to exclude hyperprolactinaemia)
- Serum TSH (abnormal in thyroid disease)
- Oral glucose tolerance test (abnormal)
- Fasting lipid panel (elevated)
Differentials for PCOS
- Thyroid dysfunction
- Hyperprolactinaemia
- Cushing’s syndrome
- Premature ovarian failure
- 21-hydroxylase deficiency
Management of PCOS
o Weight loss (restore ovulation in up to 80% of overweight patients with PCOS)
o Metformin
o Clomiphene
o Dexamethasone (When clomiphene fails to result in pregnancy, adding dexamethasone may be considered if the patient has evidence of adrenal androgen excess.)
o IVF (3rd line)
What is endometriosis?
- Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature.
- Surgical appearance varies significantly from superficial blebs to infiltrating fibrosis.
- Direct visualisation confirmed by histological examination remains essential for diagnosis.
What is the aetiology of endometriosis?
- Retrograde menstruation: represents a portal for endometrial tissue to gain exposure to peritoneal surfaces.
- Deficient cell-mediated immune response: reduced scavenger receptivity by activated, non-adherent macrophages.
- Mullerian rests: differentiation of coelomic epithelium into endometrial glands is a possible mechanism.
- Vascular and lymphatic dissemination: suggested by presence of endometriosis pulmonary disease.
History and exam of endometriosis
- Dysmenorrhoea
- Chronic or cyclic pelvic pain
- Dyspareunia
- Sub-fertility
- Uterosacral ligament nodularity
- Pelvic mass
- Fixed, retroverted uterus
- Depression
Risk factors for endometriosis
o Reproductive age
o Positive FHx
o Non-parous women
o Mellerian anomalies
Investigations of endometriosis
- Transvaginal ultrasound (TVUS)- Confirmatory for endometriomas but criteria are less well defined for peritoneal fibrosis.
- Diagnostic laparoscopy
Differentials of endometriosis
- Adenomyosis
- Interstitial cystitis
- PID
- IBS
- Ovarian cyst
- Ovarian cancer
- Neuropathic pain
- Uterine myoma
Management of endometriosis
- Combined oral contraceptive pill (if immediate fertility is not desired)
- NSAIDs
- Controlled ovarian hyper-stimulation (clomiphene)
- IVF
- Therapeutic laparoscopy
- Surgery- suspected severe/deep disease
What is anovulation?
Anovulation means lack of ovulation and is associated with either absent or irregular menstrual periods.
WHO classification of anovulation is based on measurements of FSH, LH and oestrogen.
What is the most common condition of anovulation?
PCOS is the most common condition.
Which medical agents are used for ovarian induction?
• Standard therapy is the use of gonadotropins which involves a daily injection of both FSH and LH contained together in a preparation called human menopausal gonadotrophin (hMG).
Ovulation is induced also by clomiphene which increases the production of FSH and LH.
- Response of the ovaries has to be carefully monitored with ultrasound scans (every 3-7 days) to ensure that only one follicle cell develop.
- Injections can take 8-35 days to work.
- hCG injection is given to achieve the release of the egg and intercourse advised at this time.
What is ovarian hyperstimulation syndrome?
- Ovarian hyperstimulation syndrome is an exaggerated response to excess hormones.
- It usually occurs in women taking injectable hormone medications to stimulate the development of eggs in the ovaries.
Mild to moderate symptoms of OHSS
o Mild to moderate abdominal pain
o Abdominal bloating or increased waist size
o Nausea
o Vomiting
o Diarrhoea
o Tenderness in the area of your ovaries
o Some women who use injectable fertility drugs get a mild form of OHSS.
This usually goes away after about a week. But, if pregnancy occurs, symptoms of OHSS may worsen and last several days to weeks.
Severe symptoms of OHSS
o Rapid weight gain — more than 2.2 pounds (1 kilogram) in 24 hours o Severe abdominal pain o Severe, persistent nausea and vomiting o Blood clots o Decreased urination o Shortness of breath o Tight or enlarged abdomen
Risk factors of OHSS
o Polycystic ovary syndrome — a common reproductive disorder that causes irregular menstrual periods, excess hair growth and unusual appearance of the ovaries on ultrasound examination
o Large number of follicles
o Age under 35
o Low body weight
o High or steeply increasing level of oestradiol (oestrogen) before an HCG trigger shot
o Previous episodes of OHSS
Complications of OHSS
o Fluid collection in the abdomen and sometimes the chest
o Electrolyte disturbances (sodium, potassium, others)
o Blood clots in large vessels, usually in the legs
o Kidney failure
o Twisting of an ovary (ovarian torsion)
o Rupture of a cyst in an ovary, which can lead to serious bleeding
o Breathing problems
o Pregnancy loss from miscarriage or termination because of complications
o Rarely, death
Prevention of OHSS
o Adjusting medication (start with lowest possible dose).
o Add medication that reduce the risk without affecting pregnancy such as low-dose aspirin, calcium infusions, cabergoline and quinogloide.
o Coasting- If oestrogen level is high or there’s a large number of developed follicles, stop injectable medications and wait a few days before giving HCG, which triggers ovulation.
o Freezing embryos- this gives the ovaries a rest
