Polycystic Ovary Syndrome (PCOS)

Question 1

what is polycystic ovarian syndrome (PCOS)?

Answer 1

a common condition causing metabolic and reproductive problems in women
- there are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance

Question 2

what is the aetiology of PCOS?

Answer 2

• unknown
• genetic (e.g. AD)
• post-natal obesity

Question 3

what is the pathophysiology of PCOS?

Answer 3

relates to excess androgen production, and this is usually due to one or both of:

• excess luteinising hormone (e.g. LH) production: the anterior pituitary releases gonadotropin in response to gonadotropin-releasing hormone, which leads to excess androgen production by the ovaries
• hyperinsulinemia/insulin resistance: excess insulin in the bloodstream promotes androgen production by the ovaries; hyperinsulinemia may stimulate the ovary to over-produce testosterone and prevent the follicles from growing normally to release eggs, which causes the ovaries to become polycystic

Question 4

what are the ‘cysts’ found on the ovaries of most women with PCOS?

Answer 4

• immature follicles which have had their ovulation phase arrested
• this occurs due to an elevated baseline of LH and lack of LH surge (e.g. as in a normal menstrual cycle)

Question 5

what are the risk factors for PCOS?

Answer 5

• obesity
• diabetes
• genetic
• premature adrenarche (e.g. early onset of pubic hair)

Question 6

what are the symptoms of PCOS?

Answer 6

• hirsutism
• infertility
• acne
• menstrual cycle disturbance (e.g. oligomerorrhea, amenorrhea)
• obesity
• alopecia
• depression

Question 7

what are the signs on examination of PCOS?

Answer 7

• hyperandrogenism (e.g. hirsutism, acne, alopecia, MPB)
• metabolic syndrome (e.g. hypertension, obesity, acanthosis nigricans)

Question 8

what are the investigations for PCOS?

Answer 8

• urine hCG
• capillary blood glucose
• FBC
• U&Es
• CRP
• testosterone ↑
• sex hormone-binding globulin (SHBG) ↓
• testosterone : SHBG ↑
• LH/FSH (e.g. LH ↑, LH:FSH >3)
• oral glucose tolerance test (e.g. insulin resistance)
• pelvic US (e.g. ≥12 follicles (‘cysts’) on the ovaries and/or increased ovarian volume (>10cm3))

Question 9

what is the rotterdam criteria for PCOS?

Answer 9

two of the following three criteria must be met to make a diagnosis of PCOS:

1. polycystic ovaries on ultrasound
2. oligo- or anovulation, or oligo- or amenorrhoea
3. hyperandrogenism

Question 10

what is the management of PCOS?

Answer 10

• lifestyle (e.g. weight loss, exercise, diet)
• hirsutism (e.g. shaving, electrolysis, waxing)
• combined oral contraceptive pill (COCP)
• anti-androgen (e.g. cyproterone acetate, drospirenone)
• eflornithine hydrochloride (e.g. Vaniqa)
• metformin
• orlistat (e.g. pancreatic lipase inhibitor)
• clomiphene

Question 11

what are the long-term complications of PCOS?

Answer 11

• infertility
• pregnancy (e.g. spontaneous pregnancy loss, gestational diabetes, pre-eclampsia)
• endometrial hyperplasia/endometrial cancer
• higher cardiovascular risk profile (e.g. due to metabolic syndrome, insulin resistance, diabetes, hyperlipidaemia, NAFLD and hypertension)