Polycystic Ovarian Syndrome (PCOS) Flashcards
What causes PCOS?
Cause not fully understood - a complex condition of ovarian dysfunction
What percentage of women of reproductive age are thought to be affected?
5-20%
When does it typically emerge?
Adolescence
What features are seen?
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
What is it associated with?
Metabolic syndrome
- HTN
- dyslipidaemia
- insulin resistance
Does it cause pain?
No
How is it diagnosed?
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)
What differentials are there?
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
What investigations should be done?
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)
What are the 2 most common hormonal abnormalities present in PCOS?
Excess LH (stimulating ovarian production of androgens)
LH:FSH of 3:1 is enough to disrupt ovulation
Insulin resistance - high levels of insulin secretion
Despite the high levels of LH, the increased circulating androgens suppress what?
The LH surge - required for ovulation to occur
What risk factors are there?
DM
FH of PCOS
Irregular menstruation
What stage of the cycle should blood tests be taken?
Follicular phase (best measured days 1-3)
Will progesterone levels be high or low?
Low
Will vary depending on day of cycle, but likely remains low
What is the primary intervention?
Weight loss and exercise - especially in women trying to get pregnant
In order to increase insulin sensitivity
PCOS is strongly associated with…
Mental health problems - refer appropriately
Specific management depends on…
Priorities and life stage
- desire for regular periods
- wants to conceive
- wants treatment for acne/ hirsutism
What can be done if patient wants regular periods?
COCP (better option as increases SHBG) Cyclical progestogens (not for long term use)
What can be done if infertility is main issue?
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
How can acne/ hirsutism be managed?
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
Other than weight loss, what other general advice should be given?
Smoking cessation
What facial cream can help with the acne?
Eflornithine - anti androgen
Why can spironolactone be useful?
For hirsutism and acne
Antiadrogenic
Avoid in pregnancy as teratogenic
What long term implications of PCOS are there?
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
What reduces the risk of endometrial cancer?
3-4 monthly withdrawal bleeds
Do follicles develop within the ovary?
Yes but are arrested at an early stage (due to disturbed ovarian function) - they remain visible as ‘cysts’ within the ovary
Insulin resistance results in high levels of insulin secretion..what does this suppress?
Hepatic production of sexy hormone binding globulin (SHBG) - higher levels of free circulating androgens
Are the cysts in PCOS true cysts?
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
What can high levels of up insulin cause?
Ovaries to produce too much testosterone
Weight gain - excess body fat in turn can increase insulin production
What is the role of SHBG?
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
Why can Cushing’s syndrome cause amenorrhoea?
High cortisol suppresses GnRH release
What are women with PCOS at increased risk of with assisted conception?
Ovarian hyperstimulation
Why are SHBG levels low?
Insulin resistance results in increased insulin production. This suppresses hepatic production of SHBG
What suppresses the LH surge?
The increased circulating androgens.
Follicles develop within the ovary, but are arrested at an early stage - they remain visible as cysts within the ovary
If taking clomifene citrate, what percentage conceive in first 6 months of treatment?
50-60%
Only used by specialists and in conjunction with fertility investigations, in women with BMI <35 and for no more than 6 cycles
What are 2 main risks with clomifene citrate?
Multiple pregnancy
Ovarian cancer
