Polycystic ovarian syndrome (PCOS)

Question 1

The Rotterdam criteria are used for making a diagnosis of PCOS. A diagnosis requires at least two of three features - what are they?

Answer 1

• Anovulation (no periods) or oligoovulation (irregular infrequent periods)
• Hyperandrogenism
• Polycystic ovaries on US

Question 2

Name 3 ways women with PCOS can present

Answer 2

• Oligomenorrhoea or amenorrhoea
• Infertility
• Obesity (in about 70% of patients with PCOS)
• Hirsutism
• Acne
• Hair loss in a male pattern

Question 3

Name 2 other features or complications of PCOS

Answer 3

• Insulin resistance and diabetes
• Acanthosis nigricans (insulin resistance)
• Cardiovascular disease
• Hypercholesterolaemia
• Endometrial hyperplasia and cancer
• Obstructive sleep apnoea
• Depression and anxiety
• Sexual problems

Question 4

An important feature of polycystic ovarian syndrome is hirsutism - name 2 other causes/differentials of hirsutism

Answer 4

• Medications i.e. phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
• Ovarian or adrenal tumours that secrete androgens
• Cushing’s syndrome
• Congenital adrenal hyperplasia

Question 5

When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin resistance is a crucial part of PCOS - name 2 ways it’s important/implicated in the condition

Answer 5

• Insulin promotes the release of androgens from the ovaries and adrenal glands (more insulin = more androgens)
• Insulin suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS
• The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles

Question 6

Name 3 features of a blood test in a person with PCOS

Answer 6

• Raised LH
• Raised LH to FSH ratio (high LH compared with FSH)
• Raised testosterone
• Raised insulin
• Normal or raised oestrogen levels

Question 7

1) What investigation is required for PCOS?
2) What is the gold standard investigation for visualising the ovaries?
3) What may be seen on this investigation?
4) Name 1 of the 2 diagnostic criteria for PCOS on ultrasound
5) Pelvic ultrasound is not a reliable diagnostic investigation for PCOS in what age group?

Answer 7

1) Pelvic ultrasound
2) Transvaginal ultrasound
3) follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance
4) 12 or more developing follicles in 1 ovary and ovarian volume of more than 10cm3
5) Adolescents

Question 8

1) Why is emphasising exercise and weight loss important in patients with PCOS?
2) Orlistat may be used to help weight loss in women with a BMI above 30 - what is this drug?

Answer 8

1) PCOS increases hypercholesterolemia, obesity, CVD and T2DM risk
2) Lipase inhibitor that stops the absorption of fat in the intestines

Question 9

Why might the Mirena coil or the COCP be used in PCOS?

Answer 9

Decrease endometrial cancer risk (COCP can also be used to manage acne and hirsutism secondary to PCOS)