Week 5 - PCOS Flashcards
What are the 3 most common symptoms seen in the clinical presentation of PCOS?
hirsutism (90%)
menstrual irregularity - with anovulation (90%)
infertility (75%)
define hirsutism
Hirsutism is the excessive hairiness on women in those parts of the body where terminal hair does not normally occur or is minimal — for example, a beard or chest hair. It refers to a male pattern of body hair (androgenic hair) and it is therefore primarily of cosmetic and psychological concern.
Clinical presentation of PCOS?
Obesity in 40-50% of women acne, oily skin clitoral hypertrophy polycystic or enlarged ovaries Glucose intolerance Acanthosis nigricans
Why is PCOS acne unique?
PCOS-related acne tends to flare in areas that are usually considered “hormonally sensitive,” especially the lower third of the face. This includes your cheeks, jawline, chin, and upper neck.
“Patients with PCOS tend to get acne that involves more tender knots under the skin, rather than fine surface bumps, and will sometimes report that lesions in that area tend to flare before their menstrual period,” Schlosser says. “They take time to go away.”
Define acanthosis nigricans
grey-brown, velvety discolouration of skin
usually at Neck, groin and axilla
associated with diabetes
prevalence of PCOS?
3-10% of reproductive age women
- one of the m/c endocrine disorders in women
- most frequent cause of anovulatory infertility
- spans menarche to menopause
Hyper secretion of which hormone is a key feature?
LH (increased LH/FSH ratio)
What is the consequence of increased LH?
- increase in LH leads to higher ovarian androgen production and arrests follicular development
- leads to multiple cysts on the ovaries (immature follicles), mostly without ovulation
Lack of ovulation exposes endometrium to unopposed ________, which can result in endometrial hyperplasia
Lack of ovulation exposes endometrium to unopposed estrogen, which can result in endometrial hyperplasia
potential sequelae / associated conditions
Type II Diabetes mellitus Obesity Dyslipidemia Endometrial hyperplasia and cancer Infertility Hypertension Sleep apnea Gestational diabetes Pregnancy induced hypertension Autoimmune thyroid conditions Raised liver enzymes (30%) Non-alcoholic liver disease Better bone density (YAY!) Cardiovascular disease ***
Etiology & Risk Factors
Cause is unknown
A genetic link likely exists
Not all women with PCOS are overweight/obese
Lean women with PCOS also have insulin resistance
What is the link between PCOS & insulin
Women with PCOS have what is called insulin resistance. This means that cells in the body are resistant to the effect of a normal level of insulin. More insulin is then produced to keep the blood sugar normal. This raised level of insulin in the bloodstream is thought to be the main underlying reason why PCOS develops. It causes the ovaries to make too much testosterone. A high level of insulin and testosterone interfere with the normal development of follicles in the ovaries. As a result, many follicles tend to develop but often do not develop fully. This causes problems with ovulation - hence, period problems and reduced fertility.
It is this increased testosterone level in the blood that causes excess hair growth on the body and thinning of the scalp hair.
Dx criteria
Diagnosis made with 2 of 3 criteria:
1. Oligo/anovulation
2. clinical and/or biochemical hyperandrogenism
3. Polycystic ovaries on transvaginal US where possible
AND exclusion of other causes (pituitary or adrenal disease)
DDXs?
Late onset congenital adrenal hyperplasia
primary or secondary amenorrhea (due to other causes)
Pregnancy
Thyroid dysfunction
Pituitary dysfunction (including hyper-prolactinemia)
Androgen-secreting tumours of ovary, adrenals
Cushings syndrome
Idiopathic hirsutism
Exogenous androgen administration
Work-up
Plasma LH/FSH ratio (ideally day 3). 3:1 ratio is indicative of the syndrome (but not diagnostic), but if negative, does not rule it out. Can fluctuate wildly.
Plasma testosterone (or free androgen index)
Plasma prolactin
TSH
Fasting blood glucose or glucose tolerance test
Pelvic ultrasound
