Polycystic Ovarian Syndrome

Question 1

What is polycystic ovarian syndrome?

Answer 1

Definition – endocrine disorder characterised by excess androgen production and the presence of multiple immature follicular cysts within the ovaries.

Question 2

What causes polycycstic ovarian syndrome

Answer 2

Poorly understood
Symptoms caused by two main hormonal imbalances:
• Excess LH due to increased GnRH pulse frequency resulting in high levels of androgens from the ovaries. These supress any LH surge = anovulation and the follicles don’t rupture predictably causing the cysts
• Insulin resistance and so high levels of insulin production causing suppression of hepatic production of SHBG resulting in higher levels of androgens in the blood.

Question 3

What are the risk factors for polycystic ovarian syndrome?

Answer 3

Diabetes
Irregular menstruation
Family History

Question 4

How does polycystic ovarian syndrome present?

Answer 4

Oligomenorrhoea or amenorrhoea 
Infertility 
Hirsutism 
Obesity 
Chronic pelvic pain 
Depression 
Acne
Male pattern hair loss
Hypertension

Question 5

What should you consider and attempt to exclude before diagnosing PCOS?

Answer 5

Hypothyroidism
Hyperprolactinaemia
Cushing’s disease
Exclude other causes of amenorrhoea

Question 6

What are the diagnostic criteria for PCOS?

Answer 6

Rotterdam Criteria
Diagnosis if 2/3 criteria are met
1. Oligo and/or anovulation (cycle >42 days)
2. Clinical and/or biochemical signs of hyperandrogenism: acne, hirsutism and alopecia
3. Polycystic ovaries on imaging
4. Ovarian volume > 10mL

Question 7

How should suspected PCOS be investigated?

Answer 7

USS
Bloods for: Testosterone, SHBG, LH, FSH (should be normal), progesterone (should be low).
TFTs and Prolactin
Oral glucose tolerance test

Question 8

How is PCOS managed?

Answer 8

Weight reduction – in severe cases – orlistat which is a pancreatic lipase inhibitor
In anovulation oestrogen is unopposed so to reduce the risk of endometrial cancer the COCP may help regulate the cycles and induce a monthly bleed. Should have at least 3 bleeds/yr.
COCP will also help with Hirsutism and acne however, if it doesn’t then topical eflornithine cream may be tried. Spironolactone, flutamide and finasteride may be used under specialist supervision

Question 9

What are the common complications from PCOS?

Answer 9

Obesity
Infertility
Type 2 diabetes
Endometrial Cancer

Question 10

How is infertility caused by PCOS managed and what are the side effects of these treatments?

Answer 10

Infertility
Weight reduction is key (if appropriate)

Letrozole – reduces negative feedback caused by oestrogen (side effects – fatigue and dizziness, better side effect profile than clomiphene)

Clomiphene citrate – selective oestrogen receptor modulator blocking negative feedback effect of oestrogen (side effects = multiple pregnancies, ovarian hyperstimulation syndrome and ovarian cancer so only use in 6 cycles) with or without metformin

IVF