PCOS and Hirsutism Flashcards
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood.
What is the pathophysiology of PCOS?
- insulin resistance commonly associated
- hypothalamic disturbance leads to basal increase in LH levels
- relative reduction in FSH levels
insulin resistance → hypothalamic disturbance → increases GnRH pulse frequency → acts on pituitary → relative increase in LH + relative decrease in FSH
- As there is a basal increase in LH, this prevents an ‘LH surge’ during the menstrual cycle. LH surge is important for ovulation. Therefore follicles develop in ovary but are arrested at an early stage and remain visible as “cysts” within the ovary.
Polycystic ovary syndrome produces a range of signs and symptoms, and has a varied clinical presentation.
What are the clinical features of PCOS?
- subfertility + infertility
- menstrual disturbances: oligomenorrhoea + amenorrhoea
- hirsutism + acne (due to hyperandrogenism)
- obesity
- acathosis nigricans
- male pattern hair-loss
- hypertension
- chronic pelvic pain
Differentials for PCOS include hypothyroidism, hyperprolactinaemia and Cushing’s disease.
What investigations are done for PCOS?
- pelvic USS → multiple cysts on ovaries
-
FSH, LH, prolactin, TSH + testosterone
- raised LH:FSH ratio ‘classical’ feature
- prolactin may be normal or mildly elevated
- testosterone may be normal or mildly elevated - however, if markedly raised consider other causes -
- serum total + free testosterone
- OR total testosterone + SHBG (to calc free androgen index)
- check for impaired glucose tolerance
- TSH for hypothyroidism
In the UK, the most commonly used diagnostic criteria is the Rotterdam Criteria (2003).
What is the Rotterdam criteria?
- String of pearls
- Hyperandrogenism
- Oligomenorrhoea
- Prolactin normal
Oligomenorrhoea defined as periods occurring at intervals of greater than 35 days. Two out of first three are required. But is it really PCOS if androgens are normal? Many feel this is central to diagnosis and criticise these criteria for making it optional. No mention of insulin resistance: a very common accompanying feature. Important that prolactin, T4 and cortisol levels are normal and CAH has been excluded.
What are the big four causes of secondary amenorrhoea?
- Pregnancy
- Prolactinoma
- Polycystic ovarian syndrome
- Premature ovarian insufficiency
In young women, a common cause is exercise, weight loss and stress
The management of PCOS is tailored to the woman’s individual symptoms and needs. In general, first treat any underlying conditions such as diabetes or hypertension. The advice for all women includes advice on weight loss if overweight, screening for CV risk factors and annual glucose tolerance checks.
What is the treatment for oligomenorrhoea?
- in anovulatory menstrual cycles, effect of oestrogen is unopposed due to lower levels of progesterone
- can cause endometrial hyperplasia → risk of malignancy
- important to protect endometrium by inducing at least 3 bleeds per year, done by:
- COCP (low dose)
- dydrogesterone (if COCP contraindicated)
PCOS: What is the treatment for obesity?
- achieve BMI <30
- may be enough to trigger regular menstrual cycle
- advise + encourage healthy lifestyle
- healthy diet + exercise
- helps to increase insulin sensitivity
- severe cases → orlistat (pancreatic lipase inhibitor)
PCOS: What is the treatment for infertility?
- weight loss
- ovulation induction with clomifene
- +/- metformin
- IVF with gonadotrophins
- laparoscopic ovarian drilling
PCOS: What is the treatment for hirsutism?
- shaving, waxing, electrolysis, laser
- dianette (AKA co-cyprindiol) / third-gen COC
- eflornithine cream for facial hirsutism
- anti-androgens → cyproterone, spironolactone, finasteride
PCOS: What is the treatment for acne?
- benzoyl peroxide +/- topical antibiotics
- COCP
- increased risk of VTE w/ “Yasmin” + with “Dianette”
- “Cilest” and “Brevinor” are relatively oestrogenic COCs - also helpful for acne
Hirsutism is often used to describe androgen-dependent hair growth in women, with hypertrichosis being used for androgen-independent hair growth.
What are causes of hirsutism?
- PCOS (most common)
- Cushing’s syndrome
- Congenital Adrenal Hyperplasia
- Androgen Therapy
- Obesity (due to insulin resistance)
- Adrenal tumour
- Androgen secreting ovarian tumour
- Drugs: phenytoin, corticosteroids
In the assessment of hirsutism, the Feriman-Gallwey scoring system is used where 9 body areas are assigned a score of 0-4. A score of >15 is considered to indicate moderate or sevre hirsutism.
What is the management of hirsutism?
- advise weight loss if overweight
- cosmetic techniques such as waxing/bleaching- not available on NHS
- consider used COCP such co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin)
- co-cyprindiol should not be used long-term due to inc risk of venous thromboembolism
- facial hirsutism → topical eflornithine - contraindicated in pregnancy + breast-feeding
