PCOS (Complete) Flashcards
Define PCOS
Condition characterised by hyperadrogenism, ovulation disorders and polycystic ovarian morphology
How common is PCOS in women?
Very common (1 in 4) in reproductive years
What are the main risk factors for PCOS?
Family history
Early adenarche
- Pubic hair
- Apocrine sweat glands
Obesity
What are the main clinical features of PCOS?
Menstrual irregularities:
Oligomenorrhoea
Amenorrhoea
Sub-fertiliy/infertility (Annovulation)
Hyperandrogenism:
Hirsutism
Acne (especially along jawline)
Androgenic alopecia (male-pattern baldness)
Metabolic features:
Obesity
T2DM
Acanthosis nigricans (secondary to insulin resistance)
Hypertension/hyperlipidaemia
Psychiatric features:
Deppresion
Anxiety
Low self-esteem
What is the difference between oligomenorrhoea and amenorrhoea?
Oligomenorrhoea: Absence of period >35 days
Amenorrhoea: Absence of period > 6 months OR < 1 period every 3 months
Why does acanthosis nigricans occur in women with PCOS?
Due to increased insulin sensitivity
Male-pattern baldness in females is known as?
Androgenic alopecia
What differentials should be considered alongside PCOS?
Menopause
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumour
Cushing’s syndrome
What investigations should be conducted for patients with suspected PCOS?
Bedside:
Weight + Height: Check BMI
Urine dipstick: Check diabetes
24-hour urinary cortisol: Rule out cushing’s syndrome
Bloods:
LH/FSH ratio: > 2
Total testosterone: Normal or slightly elevated
SHBG: Normal or low
Fasting and oral glucose tolerance test: Check for insulin resistance
TFTs: Check for thyroid dysfunction
17-hydroxyprogesterone: Rule out CAH
DHEAS and androgen index: Rule out androgen secreting tumours
Imaging:
Transvaginal ultraound: Check for increased ovarian volume and multiple cysts
What investigation findings are suggestive of PCOS?
LH/FSH ratio > 2
Mildly elevated testosterone levels (or normal)
SHBG: Low (or normal)
Increased ovarian volume and multiple cysts
What findings on US are suggestive of PCOS?
Increased ovarian volume
Multiple cysts
What criteria is used to diagnosed PCOS?
Rotterdam diagnostic criteria
According to the Rotterdam diagnostic criteria what findings must be found to confirm PCOS in adults?
At least 2 of the following:
Ovarian dysfunction
- Oligomenorrhoea
- Amenorrhoea
Clinical or biochemical signs of hyperandorgenism:
- Hirsutism/acne
- Elevated levels of total free testosterone
PCOS ovarian morphology: Presence of > 20 follicles in at least one ovary on US
How many follicles must be seen on at least one ovary to be considered as PCOS ovarian morphology?
> 20 follicles
or
≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries
or
Increased ovarian volume > 10 cm³
According to the Rotterdam diagnostic criteria what findings must be found to confirm PCOS in adolescents?
Evidence of hyperandrogenism AND irregular menstrual cycles
What is the management plan for PCOS?
Conservative:
Encourage weight loss
Education on increased risk of
Medicine:
Not planning pregnancy:
- First-line: COCP: Decreases irregular bleeding and protects against endometrial cancer
- Co-cyprindol: Reduces hirsutism and promotes regular cycle
- Metformin: Helps hirsutism, acne and menstruation (requires specialist input as is off-licencse)
Planning pregnancy:
First-line: Clomiphene
Second-line: Gonadotrophins (carry higher risk of multiple pregnancy)
Surgical:
Ovarian drilling: Second-line for woman planning pregnancy
Women with PCOS are at increased risk of which conditions?
Endometrial cancer
Cardiovascular disease
Diabetes
What is typically given first-line in management of PCOS for women not planning pregnancy?
COCP
Check for contraindictions (VTE risk factors)
How should COCP be taken in patients with PCOS?
Normally COCP can be taken without the requirement of a withdrawal bleed.
However, in PCOS patients a withdrawal bleed is required once every 3 months to minimise risk of endometrial cancer
What medication can be considered in women struggling with hirsutism?
Co-cyprindol
N.B. should consider other ways of managing hirsutism such as waxing
What medication is given first-line for women with PCOS who plan to conceive?
Clomiphene
Induces ovulation and enhances conception rates
What second-line options are considered for women with PCOS planning pregnancy?
Gonadotrophins
Ovarian drilling
What is ovarian drilling?
Laprascopic procedure which damages hormone producing cells in ovary
What are the main complications of PCOS?
Infertility
Metabolic syndrome and dyslipidaemia
T2DM
CVD
Hypertension
OSA
How does menopause differ to PCOS?
Starts in middle woman versus adolescent
Additional menopausal sypmtoms:
* Night sweats
* Hot flushes
Lacks features of hyperandrogenism
LH:FSH ratio is normal in menopause versus >2
How does congenital adrenal hyperplasia differ to PCOS?
Can be clinically indistinguishable from PCOS
Typically occurs at an earlier age
May have ambiguous genitalia
Raised 17-hydroxyprogesterone (>24 nmol/L)
How does hyperprolactinaemia differ to PCOS?
Presents with irregular periods and infertility but also:
Galactorrhoea
Headaches or visual field deficits
Elevated prolactin (note PCOS patients may have slightly elevated levels)
How does androgen secreting tumours differ to PCOS?
Presents with rapid onset (within months) hirsutism
Progressive virilisation
- Frontal balding
- Severe hirsutism
- Increased muscle bulk
- Deepened voice
- Clitoromegaly
Markedly raised testosterone versus mildy raised in PCOS
