Polycystic Ovarian Syndrome

Question 1

What are the key features of polycystic ovarian syndrome?

Answer 1

1. Androgen excess - hirsutism
2. Anovulation
3. Polycystic ovaries

Question 2

What are the differentials for hirsutism?

Answer 2

1. Non-classical CAH (17-OHP)
2. Cushing’s
3. Hyperprolactinaemia
4. Hyperthyroidism
5. Acromegaly
6. POI
7. Obesity
8. Virilising adrenal or ovarian neoplasm
9. Drugs side effects - e.g. steroids

Question 3

What is the pathophysiology of polycystic ovarian syndrome?

Answer 3

1. Increased LH:FSH ratio and hyperinsulinaemia causes androgen excess.
2. This causes an arrest in antral follicle development and anovulation.
3. This is due to a lack of oestrogen to reach the threshold for LH surge.

Question 4

What is the criteria for diagnosing polycystic ovarian syndrome?

Answer 4

Rotterdam Criteria (2 out of 3):

1. Clinical/biochemical hyperandrogenism
2. Oligo/amenorrhoea
3. Ovarian size/morphology on USS

Question 5

How is polycystic ovarian syndrome investigated?

Answer 5

1. Exclude other causes of irregular cycles

2. TVUSS, testosterone, SHBG, LH, FSH, AMH, 17-OHP, TSH, lipids, glucose

Question 6

If the total testosterone comes back at >5nmol/L when suspecting PCOS, what should you try to exclude?

Answer 6

Androgen secreting tumour

Question 7

What lifestyle changes should be made for PCOS?

Answer 7

Weight loss and exercise

Question 8

What is the management for PCOS?

Answer 8

1. Treat diabetes, hypertension, and dyslipidaemia
2. Hirsutism - laser photoepilation, shaving, electrolysis, eflornithine hydrochloride cream
3. COCP controls bleeding - Yasmin/Dianette
4. Finasteride (with contraception)
5. Spironolactone unlicensed (avoid in pregnancy)
6. Metformin - prevents insulin resistance and may improve ovulatory function

Question 9

What are the two ways to remove oestradiol feedback to trick pituitary into thinking there was a corpus luteum and to increase FSH in PCOS?

Answer 9

1. Block oestradiol receptor in pituitary with a SERM - clomiphene 50mg on days 2, 3, 4. Work up to 250mg.
2. Stop oestradiol being made with aromatase inhibitor - letrozole

Question 10

What are the alternative therapies for inducing ovulation in PCOS?

Answer 10

1. Gonadotrophin induction of ovulation
2. Laparoscopic ovarian diathermy
3. If all above fail then IVF

Question 11

What are the complications of PCOS?

Answer 11

1. Gestational diabetes - screen at 24-28/40
2. Type 2 diabetes
3. Endometrial cancer