Polycystic ovary syndrome (PCOS)

Question 1

Diagnostic definition of PCOS

Answer 1

• Transvaginal ultrasound
  
  • Enlarged ovaries (>10 ml) containing multiple (12 or more) small follicles
• Diagnosed when 2 out of the following 3 criteria are met:
  
  • PCO on ultrasound
  • Oligo-/amenorrhoea
  • Hirsutism
    
    • Clinical (acne, excess body hair)
    • Biochemically (raised serum testosterone)

Question 2

Pathophysiology of PCOS

Answer 2

• Affected women demonstrate:
  
  • Disordered LH production
  • Insulin resistance with compensatory raised insulin levels
• The combination of raised levels of LH and insulin acting on the PCO → increased ovarian androgen production (hirsutism)
• Raised insulin also increase adrenal androgen production
• Increased intraovarian androgens disrupt folliculogenesis → PCO + Oligo-/amenorrhoea

Question 3

Clinical features of PCOS

Answer 3

• Obese
• Acne
• Hirsutism
• Oligo-/amenorrhoea
• Miscarriage

Question 4

Investigations for PCOS

Answer 4

*PCOS is a diagnosis of exclusion*

• Transvaginal ultrasound
  
  • PCO
• Blood
  
  • **↑ Testosterone **(hirsutism)
  • FSH (anovulation)
    
    • Normal in PCOS
    • ↑ in ovarian failure
    • ↓ in anorexia nervosa
  • ↑ LH
  • Prolactin (prolactinoma)
  • TSH
• Other
  
  • Screen for diabetes

Question 5

Management of PCOS

Answer 5

• Symptomatic
  
  • Insulin insensitivity (indirectly ↓ hirsutism)
    
    • Diet and exercise
    • Metformin
  • Oligo-/amenorrhoea
    
    • COCP/Mirena (if fertility not required)
  • Hirsutism
    
    • Spironolactone
• Promote ovulation
  
  • Clomifene (anti-oestrogen)
    
    • Promotes ovulation by inhibiting oestrogen negative feedback on the hypothalamus/pituitary
  • Gonadotrophins (FSH + LH)
• IVF
• Laparoscopic ovarian diathermy
  
  • Destroy ovarian tissue responsible for androgen production

Question 6

Complications of PCOS

Answer 6

• Infertility
• Miscarriage
• Obesity
• Diabetes
• Endometrial carcinoma (unoposed oestrogen)