Polycystic Ovarian Syndrome (PCOS)

Question 1

What causes PCOS?

Answer 1

Cause not fully understood - a complex condition of ovarian dysfunction

Question 2

What percentage of women of reproductive age are thought to be affected?

Answer 2

5-20%

Question 3

When does it typically emerge?

Answer 3

Adolescence

Question 4

What features are seen?

Answer 4

Hyperandrogenism - acne, hirsutism
Obesity - associated with metabolic syndrome (HTN, dyslipidaemia, insulin resistance, visceral obesity)
Anovulation - oligo/ amenorrhoea
Subfertility
Acanthosis nigricans (due to insulin resistance)
Depression

Question 5

What is it associated with?

Answer 5

Metabolic syndrome

• HTN
• dyslipidaemia
• insulin resistance

Question 6

Does it cause pain?

Answer 6

No

Question 7

How is it diagnosed?

Answer 7

Rotterdam criteria - 2/3 must be present:

1) clinical or biochemical signs of hyperandrogenism
2) oligo/amenorrhoea
3) ultrasound features - polycystic ovaries (12 or more follicles in one or both ovaries +/ or increased ovarian volume ie more than 10cm3)

Question 8

What differentials are there?

Answer 8

Simple obesity - can cause menstruation disturbance
Thyroid disease (mainly hypothyroidism) - obesity, hair loss, insulin resistance, if severe: oligo/amenorrhoea
Hyperprolcatinaemia - oligo/amenorrhoea, acne, hirsutism
Congenital adrenal hyperplasia
Androgen secreting tumours
Cushing’s syndrome - obesity, acne, HTN, insulin resistance, depression
These should be excluded before diagnosis of PCOS made

Question 9

What investigations should be done?

Answer 9

Pelvic USS
Sex hormone binding globulin (SHBG) and total testosterone - used to calculate the free androgen index (FAI)
FSH, LH
TFT
Prolactin
Check for impaired glucose tolerance (OGTT)

Question 10

What are the 2 most common hormonal abnormalities present in PCOS?

Answer 10

Excess LH (stimulating ovarian production of androgens)
LH:FSH of 3:1 is enough to disrupt ovulation
Insulin resistance - high levels of insulin secretion

Question 11

Despite the high levels of LH, the increased circulating androgens suppress what?

Answer 11

The LH surge - required for ovulation to occur

Question 12

What risk factors are there?

Answer 12

DM
FH of PCOS
Irregular menstruation

Question 13

What stage of the cycle should blood tests be taken?

Answer 13

Follicular phase (best measured days 1-3)

Question 14

Will progesterone levels be high or low?

Answer 14

Low

Will vary depending on day of cycle, but likely remains low

Question 15

What is the primary intervention?

Answer 15

Weight loss and exercise - especially in women trying to get pregnant
In order to increase insulin sensitivity

Question 16

PCOS is strongly associated with…

Answer 16

Mental health problems - refer appropriately

Question 17

Specific management depends on…

Answer 17

Priorities and life stage

• desire for regular periods
• wants to conceive
• wants treatment for acne/ hirsutism

Question 18

What can be done if patient wants regular periods?

Answer 18

COCP (better option as increases SHBG) 
Cyclical progestogens (not for long term use)

Question 19

What can be done if infertility is main issue?

Answer 19

Reduce BMI to less than 30
Start folic acid
Baseline fertility assessment including semen analysis
Refer to fertility services
May require ovulation induction - clomifene
Metformin = controversial - currently not first line
Ovarian drilling - needlepoint diathermy in 4 places per ovary with intent of reducing steroid production

Question 20

How can acne/ hirsutism be managed?

Answer 20

COCP to reduce levels of free androgens (by increasing SHBG levels)
Treatment for acne - retinoids, antibiotics (dermatology referral)
Hair removal methods e.g waxing, laser

Question 21

Other than weight loss, what other general advice should be given?

Answer 21

Smoking cessation

Question 22

What facial cream can help with the acne?

Answer 22

Eflornithine - anti androgen

Question 23

Why can spironolactone be useful?

Answer 23

For hirsutism and acne
Antiadrogenic
Avoid in pregnancy as teratogenic

Question 24

What long term implications of PCOS are there?

Answer 24

DM
CVD
OSA 
Infertility 
Recurrent miscarriage 
Pregnancy complications - pre eclampsia, gestational diabetes 
Endometrial cancer - if not ovulating, progesterone low and endometrium exposed to long periods of unopposed oestrogen 
Psychological disorders

Question 25

What reduces the risk of endometrial cancer?

Answer 25

3-4 monthly withdrawal bleeds

Question 26

Do follicles develop within the ovary?

Answer 26

Yes but are arrested at an early stage (due to disturbed ovarian function) - they remain visible as ‘cysts’ within the ovary

Question 27

Insulin resistance results in high levels of insulin secretion..what does this suppress?

Answer 27

Hepatic production of sexy hormone binding globulin (SHBG) - higher levels of free circulating androgens

Question 28

Are the cysts in PCOS true cysts?

Answer 28

No they are not full or liquid, they do not get bigger or burst, they do not require surgical removal and do not lead to ovarian cancer.

They are follicles that have not matured to be ovulated

Question 29

What can high levels of up insulin cause?

Answer 29

Ovaries to produce too much testosterone

Weight gain - excess body fat in turn can increase insulin production

Question 30

What is the role of SHBG?

Answer 30

It binds to testosterone and oestrogen
- when these hormones are bound to SHBG, they are inactive
The availability of these hormones influenced by the level of SHBG
SHBG produced mostly by liver

Question 31

Why can Cushing’s syndrome cause amenorrhoea?

Answer 31

High cortisol suppresses GnRH release

Question 32

What are women with PCOS at increased risk of with assisted conception?

Answer 32

Ovarian hyperstimulation

Question 33

Why are SHBG levels low?

Answer 33

Insulin resistance results in increased insulin production. This suppresses hepatic production of SHBG

Question 34

What suppresses the LH surge?

Answer 34

The increased circulating androgens.

Follicles develop within the ovary, but are arrested at an early stage - they remain visible as cysts within the ovary

Question 35

If taking clomifene citrate, what percentage conceive in first 6 months of treatment?

Answer 35

50-60%
Only used by specialists and in conjunction with fertility investigations, in women with BMI <35 and for no more than 6 cycles

Question 36

What are 2 main risks with clomifene citrate?

Answer 36

Multiple pregnancy

Ovarian cancer