PCOS and hyperandrogenism - GT33 and various TOGs Flashcards
When should women with a history of PCOS be screened for GDM?
At 24-28/40
How should women with PCOS be screend for T2DM?
BMI >= 25 or normal but with risk factors (e.g. Age >40, GDM, FHx of T2DM) - 2 hour GTT
If impaired (fasting BM 6.1-6.9 or 2 hour BM >7.8 but <11.1) - annual GTT
HbA1C if GTT unacceptable - fasting not accurate
When should lipid-lowering treatment be used in PCOS?
If CV risk factors, but only by a specialist
What are the health concerns with PCOS?
- Risk T2DM/insulin resistance (65-80%)
- Cardiovascular risk
- Obstructive sleep apnoea
- Psychological issues
- Risk of endometrial Ca
When should endometrial biopsy +/- hysteroscopy be considered in PCOS?
If ET >7-9mm, appears abnormal on USS or suspected polyp
What is first line treatment for oligo/amenorrhoea?
Withdrawal bleed using progestogens (12/7) every 3-4 months
When can bariatric surgery by considered in PCOS?
If BMI >= 40 or 35 with high-risk obesity-related condition and weight loss strategies have failed
What is the prevalence of PCOS?
2.2-26%
Higher in South Asian - younger, more severe
What are the Rotterdam criteria?
- Polycystic ovaries (>=12 follicles, volume >10cm3)
- Oligo-ovulation or anovulation
- Clinical +/- biochemical signs of hyperandrogenism
What is the recommended baseline blood test for hyperandrogenism and how is it calculated?
Free androgen index
Total testosterone
————————— x 100
SHBG
What differentials should be excluded if rapid hirsutism (<1yr), virilisation, +/- testosterone >5?
Androgen-secreting tumours
Late onset CAH (17 alpha hydroxyprogesterone raised, confirmed by ACTH stimulation test)
How much more frequent is GDM in PCOS compared to general population?
x2
By how much are women with PCOS at increased risk of endometrial cancer?
x 2.89
How little weight loss could improve insulin resistance and testosterone levels in PCOS?
5%
What % of PCOS have normalisation of androgens/SHBG and persistence of ovulation for up to 20 years following lap ovarian drilling?
> 60%
What is the prevalence of PCOS?
6-7%
What is the biochemical profile in PCOS?
- Hyperinsulinism causing raised LH - potentiates LH and IGF-1
- Upregulate synthesis of androgens (adrenal and ovarian) testosterone and DHEA-S
- All cause arrest of follicles
- Overproduction of AMH antagosises FSH
What % of women with PCOS will have insulin resistance?
80%
What are the adrenal androgens?
DHEA (predominant)
DHEA-S (sulphuric acid ester) - useful measure of adrenal androgen production
Which androgens are produced by the ovary?
20% of DHEA
50% of androstenedione
25% circulating testosterone
How does testosterone circulate around the body?
80% bound to SHBG
19% bound to albumin
1% circulates freely
Which androgens can activate androgen receptors?
Testosterone
DHT (active metabolite)
How is testosterone excreted?
Metabolised in liver
Conjugated
Excreted in urine as 17-ketosteroids
Where in the brain are the highest concentration of androgen receptors?
Preoptic area of the hypothalamus - close to oestrogenic
What is the scoring system and limits for hirsutism?
Ferriman-Gallwey score
11 body areas 0-4
>=8 defines hirsutism
What testosterone level should prompt concerns of an androgenic tumour?
> 5nmol/L
What is the differential diagnosis of hyperandrogenism?
- PCOS
- Ovarian hyperthecosis
- Congenital adrenal hyperplasia (2%)
- Cushing’s syndrome
- Androgen-secreting tumour (ovarian/adrenal)
- Exogenous androgen administration
- Gestational hyperandrogenism
What is ovarian hyperthecosis?
- Accounts for most hyperandrogenism in post-menopausal
-Presence of luteinised theca cell nests in the ovarian
stroma - Testosterone may be >7
Which are the virilising ovarian androgenic tumours?
- Sertoli Leydig cell tumours (0.5% all ovarian)
- Granulosa cell
- Hilar cell
- Brenner tumours
What are the most common causes of gestational hyperandrogenism?
Luteomas
Theca lutein cysts
SHBG should go up in preg - protective
Unilateral solid androgenic masses in pregnancy - increased chance of malignancy
