Review of PCOS Flashcards
What releases estrogen in the follicular cells
Granulosa cells in the dominant follicle
What would the endometrial lining be like on 1. Estrogen only 2. Progesterone only 3. Combined pills?
- Thick
- Thin
- Thin (progesterone wins out)
How do we make the diagnosis of PCOS?
2 of 3 of:
Oligo/amenorrhea
Clinical or lab evidence of elevated androgens
Polycystic ovaries on ultrasound
Oligomenorrhea
Infrequent periods
Clinical evidence of increased androgens
Acne
Hirsutism
Balding
5 causes of irregular cycles
Hyperprolactinemia (galactorrhea and elevated prolactin) Hypothalamic amenorrhea Premature ovarian insufficiency Hypothyroidism (TSH) PCOS
Hypothalamic amenorrhea
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
Premature ovarian insufficiency
Reduction in the number of follicles
Clinically: early menopause
During menopause FSH levels are high because there is no negative feedback from estrogen
PCOS hormone problems
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
Difference in hormone levels between PCOS and hypothalamic amenorrhea
PCOS: low/medium levels of estrogen
HA: low estrogen
What is the endometrial lining like in PCOS?
Lining is thick
Because the estrogen causes compounding over time
Can get hyperplasia
Patients with PCOS present with (4)
Infertility
Irregular cycles
Acne
Hirsutism/male pattern hair loss
Clomiphene citrate
Blocks estrogen feedback at hypothalamus and pituitary
Causes increased FSH release and the possibility of ovulation
If you have hypothalamic amenorrhea, can clomiphene work for you? Why?
Nope
They don’t have any estrogen so no point blocking it!
When do you take clomiphene?
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
How can you stimulate a period
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
Letrozole
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
Is clomiphene or letrozole better?
Letrozole
5 options to treat PCOS
Clomiphene
Letrozole
FSH injections (expensive, higher risk of multiples)
IVF
Ovarian drilling (kill some of the theca cells - not really done anymore)
2 ways to reduce hirsutism/acne
Oral contraceptives
Anti-androgens
5 long term health complications from PCOS
Endometrial cancer Hypertension Dyslipidemia Type 2 DM Sleep apnea
How can you reduce the hyperplasia in PCOS?
Give progesterone!
Women with PCOS should cycle regularly
