Review of PCOS

Question 1

What releases estrogen in the follicular cells

Answer 1

Granulosa cells in the dominant follicle

Question 2

What would the endometrial lining be like on
1. Estrogen only
2. Progesterone only
3. Combined
pills?

Answer 2

1. Thick
2. Thin
3. Thin (progesterone wins out)

Question 3

How do we make the diagnosis of PCOS?

Answer 3

2 of 3 of:
Oligo/amenorrhea
Clinical or lab evidence of elevated androgens
Polycystic ovaries on ultrasound

Question 4

Oligomenorrhea

Answer 4

Infrequent periods

Question 5

Clinical evidence of increased androgens

Answer 5

Acne
Hirsutism
Balding

Question 6

5 causes of irregular cycles

Answer 6

Hyperprolactinemia (galactorrhea and elevated prolactin)
Hypothalamic amenorrhea
Premature ovarian insufficiency
Hypothyroidism (TSH)
PCOS

Question 7

Hypothalamic amenorrhea

Answer 7

Hypothalamus shuts down because body senses its not a good time to get pregnant
No FSH, LH or estrogen
See this in athletes, eating disorders, famine, mass migration

Question 8

Premature ovarian insufficiency

Answer 8

Reduction in the number of follicles
Clinically: early menopause
During menopause FSH levels are high because there is no negative feedback from estrogen

Question 9

PCOS hormone problems

Answer 9

Rapid GnRH pulsatility
Increases LH production, reduced FSH production
Theca cells are stimulated to make androgens preferentially
Granulosa cells have less FSH and dont aromatase as much to estrogen
Elevated local androgens inhibit follicular development

Question 10

Difference in hormone levels between PCOS and hypothalamic amenorrhea

Answer 10

PCOS: low/medium levels of estrogen
HA: low estrogen

Question 11

What is the endometrial lining like in PCOS?

Answer 11

Lining is thick
Because the estrogen causes compounding over time
Can get hyperplasia

Question 12

Patients with PCOS present with (4)

Answer 12

Infertility
Irregular cycles
Acne
Hirsutism/male pattern hair loss

Question 13

Clomiphene citrate

Answer 13

Blocks estrogen feedback at hypothalamus and pituitary

Causes increased FSH release and the possibility of ovulation

Question 14

If you have hypothalamic amenorrhea, can clomiphene work for you? Why?

Answer 14

Nope

They don’t have any estrogen so no point blocking it!

Question 15

When do you take clomiphene?

Answer 15

Days 3-7 of the cycle
Blocks estrogen enough to get FSH - by the time you stop the estrogen block you can get enough FSH to get the estrogen surge from the dominant follicle

Question 16

How can you stimulate a period

Answer 16

Progesterone! Pills for 10 days

Might have to do this in order to give clomiphene because it needs to be given at the appropriate part of the cycle

Question 17

Letrozole

Answer 17

Aromatase inhibitor
Take from days 3 to 7 of the cycle
Blocks the aromatase in granulosa cells causing the estrogen levels to go down - get enough FSH to make a dominant follicle

Question 18

Is clomiphene or letrozole better?

Answer 18

Letrozole

Question 19

5 options to treat PCOS

Answer 19

Clomiphene
Letrozole
FSH injections (expensive, higher risk of multiples)
IVF
Ovarian drilling (kill some of the theca cells - not really done anymore)

Question 20

2 ways to reduce hirsutism/acne

Answer 20

Oral contraceptives

Anti-androgens

Question 21

5 long term health complications from PCOS

Answer 21

Endometrial cancer
Hypertension
Dyslipidemia
Type 2 DM
Sleep apnea

Question 22

How can you reduce the hyperplasia in PCOS?

Answer 22

Give progesterone!

Women with PCOS should cycle regularly