polycystic ovary syndrome

Question 1

PCOS

Answer 1

uncertain cause
covers a syndrome of:
polycystic ovaries, in ass. w/ systemic Sx causing reproductive, metabolic and psychological disturbance

most commonly present with infertility, amenorrhoea, acne, hirsutism

Question 2

epidemiology

Answer 2

33% of women of reproductive age
seen on USS
the majority of women with polycystic ovaries do not have PCOS and do not require intervention
PCOS thought to affect 5-15% of women of reproductive age

Question 3

pathophysiology

Answer 3

unclear, but multifactorial
excess androgen production by theca cells of the ovaries (due either to hyperinsulinemia or increased LH)
insulin resistance, further increased by weight gain
increased insulin causes:
increased androgen production
reduced production of sex hormone binding globulin (SHBG) in the liver, leading to increased free testosterone
increased LH production by the anterior pituitary
raised oestrogen in some women may lead to hyperplastic endometrium

Question 4

Sx

Answer 4

oligomenorrhoea (<9 periods a year)
infertility/subfertility
acne
hirsutism
alopecia
obesity/difficulty losing weight
psych Sx - mood swings, depression, anxiety, poor self esteem
sleep apnoea

Question 5

signs

Answer 5

presence of hirsutism (upper lip, chin, nipples, line beneath umbilicus)
male pattern balding, alopecia
obesity (common, usually central)
acanthosis nigricans (insulin resistance)
signs of hyperandrogenism - clitoromegaly, increased muscle mass, deep voice

Question 6

diagnostic criteria

Answer 6

polycystic ovaries (either 12 or more peripheral follicles, or increased ovarian volume)
oligo-ovulation/anovulation
clinical and/or biochemical signs of hyperandrogenism

Question 7

DDx

Answer 7

thyroid disorder (particularly hypothyroid)
hyperprolactinemia
cushing’s
acromegaly
late onset congenital adrenal hyperplasia

Question 8

management

Answer 8

education about possible long term risks:
associations with obesity, dyslipidemia and insulin resistance increase CV risk
screening for impaired glucose tolerance and DM
warned about sleep apnoea
advise on weight control - weight loss improves fertility, psych Sx and metabolic features even with a high BMI

oligomenorrhoea/amenorrhoea may predispose women to endometrial hyperplasia, and therefore Ca

Question 9

treatment

Answer 9

co-cyprindrol - acne and hirsutism
COCP - control menstrual irregularity
metformin - less effective than COCP for menstrual irregularities, hirsutism and acne. side effects and cost may outweigh benefits
eflornithine - hirsutism
orlistat - weight loss and may improve insulin sensitivity

fertility:
clomifene - induces ovulation, proven to increase pregnancy rates. do not use for more than 6 months. increased risk of multiple pregnancy
metformin - instead of clomifene

Question 10

complications

Answer 10

infertility
endometrial hyperplasia and Ca
higher CV risk than weight matched controls
T2DM
sleep apnoea
higher risk if GDM
preterm birth
pre-eclampsia