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Polycystic ovarian syndrome (PCOS) (Complications (T2DM Sporadic,…
Polycystic ovarian
syndrome (PCOS)
Definition
Gynaecological disorder with
a triad of polycystic ovaries,
hyperandrogenism and
oligomenorrhoea in
absence of other cause
Epidemiology
Commonest female endocrine disorder
80% of anovulatory infertility
~7% females childbearing age
Pathophysiology
Unclear
Endocrine defects
Hypersecretion of LH, stimulating androgen secretion from ovary
Hyperandrogenism (increased secretion from ovary)
Reduced sex hormone binding globulin (SHBG) from the liver, so less testosterone bound, more available in active form
Genetics
Familial clustering
Obesity and insulin resistance
Obesity (central obesity)
Insulin resistance (defective insulin receptor),
compensatory hyperinsulinaemia
Clinical
presentation
Subfertility
Obesity
Acne
Hirsuitism
Oligomenorrhoea
Diagnosis
Rotterdam
criteria
2+ of the following:
Oligo/anovulation
Clinical/biochemical signs of hyperandrogenism
(acne, hirsuitism, alopecia)
Polycystic ovaries on pelvic USS or ovarian vol >10mL
Exclusion of other disorders
Investigations
Bloods
FBC, U+Es, LFTs, glucose (may be high), lipids (may be high)
Hormones (LH/FSH, PRL [normal], testosterone [may be slightly raised], DHEAS, SHBG, free androgen index [raised])
TFTs (rule out hypothyroidism)
Imaging
Pelvic USS: cystic ovaries (absence doesn't exclude PCOS)
Bedside
Obs, height/weight (BMI)
Examination
Abdo
Central obesity, hirsuitism
General
Acne, obesity, hirsuitism, alopecia,
acanthosis nigricans
Pelvic
Nil
History
POH
Gravidy/parity, conception method,
births, complications
PMH
Endocrine disorders, surgeries
PGH
Known gynae, menses, contraception,
STIs, smears
DH
Usual medications, allergies
PC/HPC
Dificulties concieving, oligomenorrhoea/
amenorrhea, hirsuitism, acne, obesity
FH
PCOS, other gynae
Cancers
SH
Living arrangements, occupation,
diet, smoking, alcohol, drugs
Complications
T2DM
Sporadic, gestational
Dyslipidemia
Obstructive sleep apnoea
Due to associated obesity
IHD
Due to obesity, DM, dyslipidemia
Endometrial cancer
Long periods of amenorrhoea results in unapposed oestrogen, increasing endometrial hypoplasia and cancer
Psychological
Low self-esteem, anxiety and depression
Fertility problems
Infertility (anovulation)
Pregnancy complications
Gestational DM
Pre-eclampsia
Preterm delivery
Miscarriage
Management
Hyperandrogenism
Medical
Anti-androgens
E.g. finasteride, spironolactone, eflornithine
CI: pregnancy (feminises a male foetus)
COCP
Indication: not needing fertility
MOA: increases SHBG,
reducing serum androgen levels
Conservative
Information and advice
Lifestyle (weight loss, diet, exercise)
Cosmetic (creams, waxing, shaving, plucking)
Menstrual irregularity
Medical
COCP
Indication: not needing fertility
MOA: ovarian inhibition, reduces unapposed oestrogen and endometrial Ca risk; reduces hirsuitism, improves acne
NB. need to have withdrawal bleeds at least 3-4m
to reduce risk of endometrial hyperplasia and cancer
Metformin
NB. not licensed for PCOS
Cyclical progesterone
Indication: not needing fertility
E.g. norethisterone PO
MOA: prevents endometrial hyperplasia,
NB. need to have withdrawal bleeds at least 3-4m
to reduce risk of endometrial hyperplasia and cancer
Progesterone IUS
Indication: not needing fertility
E.g. Mirena
MOA: prevents endometrial hyperplasia
Conservative
Information and advice
Lifestyle (weight loss, diet, exercise)
Subfertility
Conservative
Information and advice
Referral to gynae/obs for investigation
Lifestyle (weight loss, diet, exercise)
Monitoring (gestational DM with OGTT)
Medical
Anti-oestrogens
Indication: subfertile
E.g. clomifene
MOA: induces ovulation
SEs: multiple oregnancy, ovarian Ca
Gonadotrophins
Indication: subfertile
MOA: induces ovulation
Metformin
Indication: subfertile, in combo with clomifene
MOA: increases ovulation and conception rates
NB. not licensed for PCOS
Surgical
Ovarian drilling
Indication: medical methods failed
MOA: laparoscopic needlepoint diathermy,
reduces steroid production
SEs: pre-eclampsia, large baby,
preterm birth, gestational DM
IVF
Indication: other methods failed
Hyperinsulinaemia
Conservative
Information and advice
Lifestyle (weight loss, diet, exercise)
Monitoring (weight, HbA1C, lipids, QRISK)
Medical
Metformin
Indication: hyperglycaemia
MOA: increases insulin sensitivity
Prognosis
Chronic condition, no cure
Differentials
Neoplastic
Androgen-sec tumour
(adrenal, ovarian)
Drugs
Steroids, OCPs
Ciclosporin, phenytoin
Endocrine
Obesity
Pregnancy
Hypothyroidism
Premature ovarian failure
Hyperprolactinaemia
Late onset CAH
Cushing's syndrome
Acromegaly