Polycystic Ovarian Syndrome

Question 1

Rotterdam criteria for PCOS

Answer 1

• There are three and you only need two:
  
  1. Hitsory of irregular menses
  2. Physical or laboratory signs of hyperandrogenism
  3. Polycystic ovaries

Question 2

Physical exam findings frequently associated with insulin resistance

Answer 2

• Hidradenitis suppuritiva
• Difficulty losing weight
• Skin tags
• Keratosis pilaris
• Acanthosis nigricans

Question 3

Keratosis pilaris

Answer 3

Dry, rough patches and tiny bumps, usually on the upper arms, thighs, cheeks or buttocks.

Question 4

Use of AMH in assessing for PCOS

Answer 4

• AMH is secreted in proportion to the # of remaining eggs
• SO. . . high AMH for someone’s age indicates a history of anovulation
  
  • This is seen in PCOS due to low FSH
  • The medical term for this is “premature ovarian insufficiency”

Question 5

Tests for evaluating laboratory evidence of hyperandrogenism

Answer 5

• Total testosterone
• Free testosterone
• DHEA sulfate

What not to order: DHEA (without the sulfate) and LH/FSH (only on tests)

Question 6

Baseline tests for evaluation of oligomenorrhea

Answer 6

• Pregnancy test
• Prolactin
• TSH

Question 7

Problem-based pharmacotherapy guide for PCOS

Answer 7

Question 8

___ looks a lot like PCOS

Answer 8

Non-classical congenital adrenal hyperplasia looks a lot like PCOS

Largely because it doesn’t manifest until later in life, individuals are phenotypically female, and it also invovles hyperandrogenism

Question 9

Normal DHEAS in a man vs a woman

Answer 9

• Woman: DHEAS < 100 is normal
• Man: DHEAS 100-450 is normal

Question 10

Interpreting DHEAS in a woman presenting with a chief complaint of hyperandrogenism

Answer 10

• DHEAS < 100 – normal
• DHEAS 200-400 – Likely PCOS
• DHEAS >500 – Likely CAH

Question 11

Primary vs secondary premature ovarian insufficiency

Answer 11

• Primary: Not enough viable eggs, so menopause will set in early. Characteristically LOW AMH on lab testing.
• Secondary: Eggs are viable, but there is chronic anovulation. Characteristically HIGH AMH on lab testing.

Question 12

Ideal OCPs for women with PCOS

Answer 12

• Standard estrogen dosage – ethinyl estriol 35 mcg
• Low, non-androgeneic progesterone dosage – norgestimate or drospirenone

Question 13

“Ring of pearls”

Answer 13

Term used to describe the apperance of the cysts in PCOS

Question 14

The obesity-hirsuitism feedback loop in PCOS

Answer 14

The key fact here is that high-level estrone is a positive stimulator of LH in PCOS

Question 15

If you think someone has PCOS, what sequence of lab tests should you order?

Answer 15

Question 16

If physical exam is normal or mild, but patients is concerned about hirsuitism, trial with one of the following medications for 6 months is reasonable:

Answer 16

• sdfa
• If this fails to improve symptoms, then hormonal workup (DHEAS, prolactin, TSH, ACTH, cortisol, IGF1, 17-HP) is warranted

Question 17

Percentage of andorenic hormone (DHEAS, androstenedione, testosterone) that comes from the ovaries vs the adrenals vs the periphery

Answer 17

Question 18

Hyperthecosis

Answer 18

Most severe form of PCOS

Rapid virilization, hirsuitism, male-pattern balding, and deepening of the voice. High DHEAS and testosterone. Difficult to treat with OCP alone and more difficult to achieve ovulation.