sub/infertility (PCOS + endo) Flashcards
PCOS presentation
- sub/infertility
- menstrual disturbances - oligomenorrhoea + amenorrhoea
- hirsutism, acne - due to hyperandrogenism
- obesity
- acanthosis nigricans - due to insulin resistance
aetiology of PCOS
not fully understood
- both hyperinsulinaemia + high levels of luteinising hormone are seen
PCOS investigations
pelvis US - multiple cysts
FSH, LH, TSH, testosterone + sex hormone binding globulin
- raised LH:FSH ratio is classical feature
- prolactin + testosterone may be normal or mildly elevated
- SHBG is normal to LOW
check for impaired glucose tolerance
what diagnostic criteria is used in PCOS
Rotterdam criteria
what is the Rotterdam criteria
a diagnosis of PCOS can be made if 2 of the following 3 are present:
- infrequent/no ovulation
- clinical +/- biochemical signs of hyperandrogenism - hirsutism, acne, elevated total or free testosterone)
- polycystic ovaries on US, presence of >=12 follicles in one or both ovaries +/- increased ovarian volume >10cm
management of PCOS + sx
weight reduction (if approp)
COCP - may regulate her cycle
hirsutism + acne
- COCP - 3rd gen one has fewer androgenic effects, increased VTE risk
- topical eflornithine (if no respond to COCP)
- spirnolactone, fluramide, finasteride - under specialist supervision
management of infertility in PCOS
weight reduction (if approp)
clomifene - risk of multiple pregs (anti-oestrogen therapy)
- metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
(metformin not first line)
secondary amenorrhoea
cessation of menstruation for 3-6months in women with previously normal + regular menses
or 6-12months in women with previous oligomenorrhoea
causes of secondary amenorrhoea
- hypothalmis amenorrhea - stress, excessive exercise
- PCOS
- hyperprolactinomaemia
- premature ovarian failure
- thyrotoxicosis
- sheehans syndrome
- Ashermans syndrome (intrauterine adhesions)
sheehans syndrome
when pituitary gland is damaged due to severe blood loss during childbirth (postpartum hypopituitarism)
- inability to breastfeed
- decreased libido
- secondary amenorhoea
investigations of amenorrhea
exclude preg
FBC, U&Es, TFTs, coeliac screen
gonadotrophins
- low levels = hypothalmic cause
- raised levels = ovarian prob (premature ovarian failure) or Turners
prolactin
androgen levels - raised in PCOS
oestradiol
infertility stats
affects 1 in 7 couples
couples who have regular sex, will conceive
- 1 year - 84%
- 2 years - 92%
causes of infertility
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other - 15%
basic infertility investigations
semen analysis
serum progesterone 7 days prior to expected period
- for 28day cycle = day 21
interpretation of day 21 serum progestogen
<16 - repeat, if consistently low refer
16-30 - repeat
> 30 - indicates ovulation
key management/advice for couples struggling to conceive
folic acid
aim for BMI 20-25
regular sex every 2-3days
smoking/drinking advice
semen analysis
should be performed after min of 3 days + max 5 days abstinence
- needs to get to lab within 1hr
pH should be >7.2
endometriosis
characterised by ectopic growth of endometrial tissue outside the uterine cavity
common condition - 10% of women of reproductive age
endometriosis presentation
chronic pelvic pain
secondary dysmenorrhea - pain start before bleeding
deep dyparenunia
subfertility
urinary symptoms
dyschezia = painful bowel movements
on pelvis exam - reduced organ mobility, tender nodularity in posterior vag fornix, visible vaginal endrometriotic lesions may be seen
endometriosis investigation
laparoscopy = gold standard
management of endometriosis
1st line symptomatic mx = NSAIDS +/- paracetamol
dont help - COCP
if fertility priority - **GnRH analogues **
- (drug therapy does not help with fertility much)
surgery
- if not responded to others
- for those trying to conceive
–> excision/ablation of endometriosis plus adhesiolysis
