Polycystic Ovarian Syndrome

Question 1

PCOS:

How when and why it presents?

Answer 1

• presents as infertility, oligomenorrhoea, hirsutism (70%), obesity (50%)
• strong hereditary basis
• Can present at any-time during reproductive years

Hyperinsulinaemia -> ovarian androgen production -> reduced hepatic SHBG production -> increased available testosterone

Question 2

PCOS:

Diagnosi?

Answer 2

Diagnosis:
2 out of 3
* Oligomenorrhoea
* Polycystic ovaries (in adults NOT adolescent as they have polycystic morphology as a baseline) OR elevated AMH
* Clinical or biochemical Hyperandrogenism (acne, hirsutism, alopecia)

Oligomenorrhoea is different dependent on time from menarche
* >1 year post menarche = >3 monthly menses
* 1 – 3 years = <21 days OR >45 days
* >3 years = <21 days OR >45 days OR <8 menses a year

*Biochemical hyperandrogenism
ONLY test if NO hormonal contraception for at least 3 months
* Free Androgen Index (FAI) – this takes into account free testosterone and SHBG

Question 3

PCOS:

Things to consider as differentials?

Answer 3

Exclude
• Cushing’s syndrome (violaceous striae can be a clue) = late night salivary cortisol

• Hyperprolactinaemia (hirsutism is not prominent) = prolactin level
• Hypothyroidism (results in low SHBG = rise in available androgens) = TSH
• Late onset adrenal hyperplasia (very close mimic if LH:FSH ratio is high) = 17 hydroxyprogesterone level
• Androgen secreting tumour (virilisation, clitoromegaly, deepening voice) = testosterone, DHEAS, androstenedione

Question 4

PCOS:

Management?

Answer 4

Management
1) Educate early about condition
• Ask PCOS App
• Self management is essential for good outcomes

2) Lifestyle factors (for mental health, reducing cardiovascular risk and healthy body weight)
*5 – 10% weight loss is the aim
• Nutrition
• Physical activity
• Stress
• Sleep

3) Prevent Oligomenorrhoea
Oligomenorrhoea = endometrial carcinoma risk

a) COCP typically (increases SHBG levels = lower testosterone)
• Standard approach to COCP prescribing initially
• Then consider COCP containing cyproterone or drospirenone as they may have added hyperandrogenism benefits (Brenda, Isabelle, Yaz) *not proven based on evidence

b) Progestogen
• Medroxyprogesterone 10mg (or Norethisterone 5mg), daily for 10 - 12 days every 3 months to induce withdrawal bleed

4) Minimise Hyperandrogenism
a) COCP as above
b) shaving, waxing, threading, depilatory creams, electrolyses and laser
c) Eflornithine cream (irreversibly inhibits ornithine decarboxylase which is required for hair growth) slows hair growth
d) Spironolactone
*minimal evidence for spironolactone and specific antiandrogen targeted COCPs
e) Cyproterone (similar antiandrogen activity to spironolactone but with more progestogenic action)
• Preferred choice in younger post menopausal women (50 – 55yo)
• Side effects include fatigue, weight gain, breast tenderness and reduced libido
• Should be used with oestrogen
• 50mg daily for first 10 days of cycle (has long half life weans off by end of withdrawal bleed when coinciding with COCP)
• The withdrawal bleed can be avoided by taking a lower dose (25 – 50mg) continuously

5) Prevent Diabetes
*5 – 10% weight loss is the aim
a) Screen with Oral Glucose Tolerance Test (OGTT) 1 – 3 yearly as more useful screening in this population
b) Metformin
• Assist with weight loss
• Prevents weight gain
• prevents diabetes
• start 500mg daily, increasing fortnightly by 500mg and aim for 1g Immediate release or 2g modified release per day

Question 5

PCOS:

Fertility considerations/management?

Answer 5

Fertility

• *refer to specialist if > 6 months without success after age 35yo**
• I would refer anyone over 30yo without success after 6 months to prevent mental health burden and time delay to conception

1) Letrozole
2) Clomiphene
• competitive hypothalamic oestrogen receptor antagonist preventing normal negative feedback mechanism resulting in elevated pituitary LH release inducing ovulation
• side effects include hot flushes, abdominal discomfort, visual disturbances and rarely OHSS
• maximum 6 cycles

3) Metformin immediate release (reduce androgen levels and increase ovulation rates; regardless of BMI)
• Most benefit for fertility in women with BMI under 30