Polycystic Ovarian Syndrome

Question 1

What % of reproductive age women are affected by PCOS?

Answer 1

5-20%

Question 2

What are the features of PCOS?

Answer 2

• Subfertility and infertility
• Menstrual disturbances: oligomenorrhea and amenorrhoea
• Hirsutism, acne (due to hyperandrogenism)
• Obesity
• Acanthosis nigricans (due to insulin resistance)

Question 3

What investigations can be done for PCOS?

Answer 3

• Pelvic ultrasound: multiple cysts on the ovaries
• FSH, LH, prolactin, TSH, and testosterone are useful investigations:
  
  • Raised LH:FSH ratio is a ‘classical’ feature (2:1 or 3:1) but is no longer thought to be useful in diagnosis.
  • Prolactin may be normal or mildly elevated.
  • Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
• Check for impaired glucose tolerance

Question 4

What is some general management advise for patients with PCOS?

Answer 4

• Weight reduction
• COCP may help to regulate her cyce and induce monthly bleeds.

Question 5

How can you manage acne and hirsutism?

Answer 5

• A COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol (Dianette) which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
• If doesn’t respond to COC then topical eflornithine may be tried
• Spironolactone, flutamide and finasteride may be used under specialist supervision

Question 6

How can you manage their infertility?

Answer 6

• Weight reduction if appropriate
• The management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
• A 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
• Metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
• Gonadotrophins

Question 7

What are the diagnostic criteria for PCOS?

Answer 7

2 out of 3 of the following:

1. Irregular/Infrequent periods
2. Polycystic ovaries on USS. (12 or more follicles that are >10cm)
3. Hyperandrogenism (Clinical signs like hirsutism or high testosterone in blood tests)