week 1- PCOS Flashcards
PCOS is characterized by
irregular periods, high androgen levels, polycystic ovaries
greater prevalence of PCOS if
overweight/ obese
also genetic and race/ethnicity
PCOS associated with
metabolic syndrome, insulin resistance, obesity, T2D, CVD, endometrial hyperplasia, cancer, perinatal complications
clinical presentation in PCOS
- Menstrual Dysfunction
- Hyperandrogenism
- Insulin resistance
- Dyslipidemia
- Obesity
- Obstructive Sleep Apnea
- Metabolic syndrome and cardiovascular disease
- Endometrial Neoplasia
- Infertility
- Complications in pregnancy
- Psychological health
short term risks associated with PCOS
- Obesity
- Infertility
- Obstructive sleep apnea
- Irregular menses
- Endometrial hyperplasia
- Depression/anxiety
- Abnormal lipid levels
- Non-alcoholic fatty liver disease
- Hirsutism/acne/androgenic alopecia
- Insulin resistance/acanthosis nigricans
- Pregnancy-related complications
long term risks associated with PCOS
- Endometrial cancer
- Type 2 Diabetes mellitus
- Cardiovascular disease
menstural dysfunction
oligomenorrhea, anovulation, and/or heavy menstrual bleeding
what does anovulation lead to
Lack of ovulation→lack of progesterone production by corpus luteum→constant estrogen exposure→constant stimulation of the endometrium
menstrual dysfunction is common and normal at
menarche (1st period)
cycle length to evaluate
Menstrual intervals <20 days or >45 days in girls >2 years after menarche OR a menstrual interval >90 days anytime after menarche merits consideration for evaluation
endometrial hyperplasia
irregular thickening of endometrium - precancerous
anovulation causes prolonged exposure of endometrium to estrogen, without progesterone exposure
risks for endometrial cancer
PCOS, obesity, T2DM
if have PCOS how often to induce bleeds
every 3-4 months
reduce endometrial cancer risk via
oral contraceptive pills or long-acting progestin (i.e. IUD)
measure endometrial thickness in women without withdrawal bleeds via
transvaginal ultrasound
routine screening with ultrasound
not recommended
when to do endometrial assessment
any woman older than 45 years with abnormal uterine bleeding or younger than 45 with a history of unopposed estrogen.
clinical manifestation of hyperandrogenism
acne, hirsutism, androgenic alopecia
what does hyperandrogegism NOT present with
if these symptoms occur then look for
typical of virilization: deepening voice, increased muscle mass, clitoromegaly.
If these are present, look for androgen producing tumour.
hirsutism
Coarse, dark, terminal hair distributed in a male pattern.
PCOS is cause of ___ % of hirsutism
70-80%
most common spots for hirsutism
upper lip, chin, sideburns, chest and linea alba.
race and ethnicity effect what in hair follicles
concentration of androgen sensitive hair follicles.
acne when to be suspicious of PCOS or androgen excess
in later onset (its common in adolescence)
how does androgen excess cause acne
overstimulation with androgens elevates sebum production which leads to inflammation and comedone production.
androgenic alopcia
thins at crown, but frontal hairline intact
–> female pattern less common in PCOS
–> also look if thyroid, IDA
insulin resistance and compensatory hyperinsulinemia contribute to
hyperandrogegism and PCOS
insulin resisntance and PCOS
can impact if lean or obese
underlying mechanism for long term health risks of PCOS
insulin resistance
dylipidemia in __% PCOS
70%
dyslipedmia metrics in PCOS
increase LDL and triglycerides
elevated cholesterol: HDL ratio
low HDL levels
obesity and PCOS
CVD and insulin resistance too
obstructive sleep apnea
and PCOS and obesity
4 characteristics of metabolic syndrome
insulin resistance
obesity
dyslipidemia
hypertension
prevalence of metabolic syndrome in PCOS
45%
cardiovascular disease and myocardial infarction risk in PCOS
7x greater
and high risk post-menopause
PCOS and infertility caused by
anovulatory cycles
recommendation for anovulation screening
Endocrine society guidelines recommend screening for anovulation, even in people with PCOS with eumenorrhea (who are trying to get pregnant).
how to measure anovulation
mid- luteal phase serum progesterone
pregnancy complications from PCOS
miscarriage, gestational diabetes, pregnancy induced hypertension, preterm birth
all especially if obese
For those using ovulation induction medications to conceive, higher rate of multifetal gestation.
psychological health and PCOS
anxiety, depression, eating disorders, negative body image
SCREEN for anxiety and depression
diagnostic criteria for PCOS
Rotterdam criteria, and the significance of ultrasonography, laboratory tests, and imaging studies in diagnosing PCOS.
when was rotterdam criteria established
2003
criteria for Rotterdam for PCOS
2 of the 3
- Chronic anovulation
- Clinical or biochemical hyperandrogenism
- Polycystic ovarian morphology
- AND the exclusion of related disorders such as thyroid dysfunction, nonclassic congenital adrenal hyperplasia (NCAH), hypogonadotropic hypogonadism (hypothalamic amenorrhea), premature ovarian insufficiency, hyperprolactinemia.
irregular menses then consider
PCOS
irregular menstural cycles
- Normal in the first year post menarche as part of the pubertal transition
- > 1 to < 3 years post menarche: < 21 or > 45 days
- > 3 years post menarche to perimenopause: < 21 or > 35 days or < 8 cycles per year
- > 1 year post menarche > 90 days for any one cycle
- Primary amenorrhea by age 15 or > 3 years post thelarche (breast development)
androgen producing tumor symptoms
increased muscle mass, voice deepening and clitoromegaly are signs of exposure to greater levels of androgens and are not signs of PCOS. This usually reflects an androgen producing tumour of the ovary or adrenal gland.
what happens to hair follicle in hyperandrogenism
Hair follicle transforms to a terminal hair follicle with exposure to testosterone. This occurs in androgen sensitive areas.
what is used to assess hirsutism
ferriman-gallwey score
score from 1-4 in 9 areas
score to get for hirsutism
> 4-6
if far-east asian >3 (because lower density hair follicles)
female androgenic alopecia
hair slowly diffuses at the crown but frontal hairline is preserved
a less common finding for hyperandrogegism than hirsutism and acne
biochemical hyperandrogenism
-elevated total and free testosterone
-elevated DHEA-S
do you need to assess biochemical androgens?
not if patient meets clinical criteria (acne, hirustism, androgenic alopecia)
what is used to detect polycystic ovarian morphology (PCOM)
transvaginal ultrasound
Rotterdam 2004 criteria for polycystic ovarian morphology (PCOM) vs AE and PCOS society new definition
12 follicles (“cysts”) measuring 2-9mm in the whole ovary or ovarian size >10ml
AE- 25 follicles (2-9mm) in the whole ovary
if ultrasound not available what do you use to diagnose PCOS
anti-mullerian hormone (AMH) which measures the ovarian reserve (follicle count)
PCOM recommended?
what happens to follicle # over lifespan?
- Follicle number per ovary declines over the reproductive lifespan
- There is no definitive criteria for PCOM in adolescents, therefore US assessment of ovaries is not recommended
thyroid test if signs of hyperandrogenism?
limited value bc dysfunction common
should do routine screening
test TSH
non classic congenital adrenal hyperplasia (NCAH)
autosomal recessive genetic disorder
deficient in 21-hydroxylase enzyme
causes excess androgens
test for non classic congenital adrenal hyperplasia (NCAH)
basal morning 17-OH progesterone
hypogonadotropic hypogonadism or functional hypothalamic amenorrhea
what is the pathway and result
Suppression of the hypothalamic-pituitary-ovary (HPO), resulting in suppression of GnRH secretion, FSH and LH secretion→suppression of estrogen from ovaries
hypogonadotropic hypogonadism or functional hypothalamic amenorrhea tests and findings
estradiol (E2), follicle stimulating hormone (FSH). (both low)
premature ovarian insufficiency
early loss of ovarian reserve and function before age 40
tests for premature ovarian insufficiency
estradiol (E2) (low), follicle stimulating hormone (FSH) (high).
hyperprolactinemia
high prolactin causes oligo-ovulation
causes of hyperprolactinemia
some physiologic like pregnancy, lactation, nipple stimulation, stress.
Some pathologic: pituitary adenoma (prolactin-secreting), acromegaly.
test for hyperprolactinemia and caveat
Prolactin (caveat: hyperandrogenism→prolactin levels in the upper normal limit or slightly above normal)
DDX for anovulation (secondary amenorrhea)
- pregnancy (most common)
-ovarian disease 40% (PCOS, premature ovarian failure)
-hypothalamic dysfunction 35% (stress, weight loss, eating disorder)
-pituitary disease 19% (tumors)
-uterine 7%
-other; acromegaly, NCAH, post pill
Rotterdam guidlines when DDX PCOS
all anovulation causes from above and hyper- or hypothyroidism, non-classic congenital adrenal hyperplasia
hypothalamic amenorrhea
low body weight, eating disorder, excessive exercise
hormones in hypothalamic amenorrhea
FSH, LH, estradiol all low
premature ovarian insufficiency
vasomotor sx (hot flashes) and urogenital sx (vaginal dryness)
premature ovarian insufficiency hormone findings
high FSH, low estradiol
androgen secreting tumor
rapid voice change, clitoromegaly
REFER
hormones in androgen secreting tumor
elevated testosterone and DHEAS
cushing syndrome
buffalo hump, hypertension, purple striae
REFER
hromones in cushing syndrome
elevated cortisol
acromegaly
accompanied by change in hat or glove size, protruding jaw, impaired vision
REFER
acromegaly lab findings
elevated insulin-like growth factor
functional ovarian hyperandrogegism (FOH) definition
dysregulation of ovarian androgen secretion, causing an over-secretion of androgen hormones by the ovary.
nearly all causes of PCOS are due to
Functional Ovarian Hyperandrogenism (FOH)
what causes Functional Ovarian Hyperandrogenism (FOH)
Caused by dysregulation of androgen secretion in the ovary and an over-response of 17-OH progesterone to gonadotropin stimulation from the pituitary.
genetic or environmental
primary clinical features of Functional Ovarian Hyperandrogenism (FOH)
hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology
diagnose PCOS
history, physical exam and basic labs (without ultrasound)
diagnosis of exclusion (rule out others)
history in PCOS
Ask questions related to menstrual history, fluctuations in patient’s weight and how they relate to symptoms of PCOS, cutaneous findings (terminal hair, acne, alopecia, acanthosis nigricans, skin tags).
- Ask about clinical findings related to comorbidities of PCOS.
medical emergency in amenorrhea (rare)
- Recent unprotected intercourse with male partner: pregnancy
- Headaches, galactorrhea, loss of peripheral vision: pituitary tumour
- Low body weight and impaired body image: anorexia nervosa
endometrial hyperplasia when to induce bleeds
if >3-4 months
impaired glucose tolerance and T2DM
when to repeat
fasting and 2-hour 75 gram oral glucose load. If normal, should be repeated every 3 years or earlier if signs are present.
when to assess OGTT
every 2 years or annually if impaired glucose tolerance (IGT)
take BP, BMI, WC,
every visit for PCOS
PCOS impacts on quality of life
- Psychosexual function
- Negative body-image
- Loss of feminine identity
- Lower self-esteem
- Disordered eating
- Depression/anxiety
- Overall lower quality of life
