Subfertilty: PCOS + anovulation problems

Question 1

What are the causes of anovulation ? (4)

Answer 1

PCOS
Hypothalamic causes
Hyperprolactinaemia
Hypothyroidism

Question 2

What % of Anovulation does PCOS account for ?

Answer 2

80%

Question 3

What is the mnemonic for requirement of the diagnosis of PCOS and state what they are ?

Answer 3

HIP;
Hirsutism
Irregular periods; 5 or more weeks apart
Polycystic ovaries on USS

Question 4

What does polycystic ovaries mean ? 😭

Answer 4

Polycystic ovaries are those that are slightly larger than normal ovaries and have twice the number of follicles, which are fluid spaces that release an egg when you ovulate

Question 5

What is the mnemonic for the clinical features of PCOS and state what they are ?

Answer 5

SOO’ HIM; Subfertility 
Oligomenorhea/ amennorhoea
Obesity 
Hirsutism and Acne 
Insulin resistance: diabetes and Acanthosis nigricans; Miscarriage

Question 6

What are 3 investigations would you do for PCOS ? 😭

Answer 6

1. TVUSS, 2. hormones (6): FSH: Normal, LH: raised, AMH, testosterone; prolactin and TSH; 3. fasting lipids and glucose

Question 7

What is the first line management for PCOS ?

Answer 7

Lifestyle changes: lose weight if overweight, stop smoking, reduce alcohol content; healthy diet and exercise

Question 8

What medications are given for hirsutism?

Answer 8

COCP if not wishing to have a or cryproacetate and spinorolactone (conception must be avoided)

Question 9

What is first line medications for a female suffering from PCOS wishing to have children ?

Answer 9

Clomifene with/without metformin

Question 10

What are the 2nd line treatments available for PCOS suffers wishing to have children ?

Answer 10

Ovarian diathermy or gonadotrophins

Question 11

If 2nd line treatment fails, what is the last resort ?

Answer 11

IVF

Question 12

What are 4DDx for PCOS ?

Answer 12

1. Hypothyroidism; 2. Hypothalamic courses (hypothalamic hypogonadism; 3. Hyperprolactinaemia 4. Cushing syndrome

Question 13

Describe how hypothalamic gonadism can cause anovulation and state what it is associated with ?

Answer 13

Reduction in GnRH causes Amenorrhoea due to a decrease in FSH and LH, which In turn reduces Oestradiol. It is associated with women who have anorexia nervosa, on diets, athletes/excessive exercise or under stress

Question 14

Kallmans syndrome is a hypothalamic cause of anovulation ? Describe it

Answer 14

Kallmans syndrome occurs when the GnRH neurone fail to develop properly

Question 15

Describe how hyperprolactinaemia causes anovulation

Answer 15

Excess prolactin levels can reduce GnRH release, which can be due to pituitary adenomas or hyperplasia of the pituitary gland

Question 16

What does the treatment of hypothalamic causes involve ?

Answer 16

Lifestyle changes: restore weight if it fails or weight is normal: give GnRH analogues will induce ovulation but it must be followed by HRT

Question 17

What are the associations of hyperprolactinaemia ? (3)

Answer 17

PCOS, hypothyroidism and psychotropic drugs

Question 18

What are the clinical features of Hyperprolactinaemia? (2)

Answer 18

Oligomenorrhoea/Amenorhoea this Subfertility
Galactorrhoea
Vision problems

Question 19

What does the treatment of hyperprolactinaemia involve?

Answer 19

Dopamine agonist: bromocriptine or Cabergoline