Polycystic Ovarian Syndrome

Question 1

What are polycystic ovaries?

Answer 1

Affects between 5-20% of women of reproductive age

Aetiology not entirely understood - some genetic component (possible AD inheritance with variable expressivity), severity impacted on by obesity

Excessive LH release from anterior pituitary and/or hyperinsulinaemia stimulate the ovaries to produce excessive testosterone (an androgen) and also stimulate the formation of many immature follicles

Question 2

How do polycystic ovaries present?

Answer 2

Rotterdam criteria: 2/3 of the following

1. 12+ follicles OR one ovary OR volume <10cc on USS
2. Anovulation, amenorrhoea/oligomenorrhoea
3. Raised androgens - biochemically or clinically e.g. hirsutism, acne, hair thinning

Also infertility

Question 3

What blood results might you find in PCOS?

Answer 3

LH - high
FSH - normal/low
LH:FSH - >2-3:1

Prolactin - normal/high

Testosterone - high
Oestrogen - normal/high

Sugars:

• Fasting/OGTT - high
• HbA1c - high
• Hyperinsulinaemia - majority of the patients have some insulin resistance which have a knock on effect on HPA axis (and subsequent fertility - hence why metformin works - increases peripheral insulin sensitivity)

TSH - sometimes high, as women can often be hypothyroid too

Cortisol - to exclude Cushing’s
IGF-1 - to exclude acromegaly

Question 4

How would you manage PCOS?

Answer 4

If women wants contraception/not a baby:
COCP - to regulate cycle/monthly bleed, manage unwanted hair growth (hirsutism)

If a woman wants a baby:
1st line - weight loss, if overweight

2nd line - clomiphene:
Nonsteroidal that acts as a selective estrogen receptor modulator (SERM) - release LH/FSH from anterior pituitary - production of oestrogen + stimulation of follicle (=ovulation)
For no more than 6 cycles (as possible risk of ovarian hyperstimulation syndrome)
Monitor with progesterone levels and USS
Also increased risk of multiple pregnancy

Adjunct - metformin:
Less effective than clomiphene alone
Less effective in obese
Useful if resistant to clomiphene

Ovarian drilling:
Surgical option after others fail, improves ovulation and pregnancy rates

Question 5

What are some other causes of amenorrhoea?

Answer 5

Primary:
14yrs + not menstruated + no secondary sexual development OR
16yrs with some sexual characteristics
E.g. agenesis of Müllerian ducts (e.g. imperforated hymen, cervical agenesis), congenital adrenal hyperplasia, kallmans syndrome, androgen insensitivity syndrome, turners syndrome

Secondary:
PCOS, premature ovarian failure
HPG axis dysfunction (e.g. stress, low weight, over exercise)

Question 6

What are prolactinomas?

Answer 6

Prolactin tumour in anterior pituitary

Presents with symptoms of hypooestrogen + hyperprolactinaemia:
Anovulatory infertility, amenorrhoea/oligomenorrhoea
Beast milk production
Loss of libido
Vaginal dryness

May need resection if tumour; treat symptoms with bromocryptine - DA agonist