Gynaecology Pg No 91 -100
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What is one of the main sources of excessive androgen production in females?

  • Adrenal glands
  • Pancreas
  • Ovaries (correct)
  • Liver

    • PCOS is also known as Stein-Leventhal syndrome.

    True

    Name one genetic factor associated with PCOS.

    Chromosome no. 2

    Excessive production of androgens in PCOS can lead to defects in ______ and ______.

    <p>folliculogenesis, insulin action</p> Signup and view all the answers

    Match the following factors with their categories related to PCOS:

    <p>Excessive androgen production = Clinical manifestation Insulin resistance = Metabolic defect Obesity = Lifestyle factor Defect in gonadotropin secretion = Hormonal imbalance</p> Signup and view all the answers

    Which hormone level is typically elevated in a patient with Polycystic Ovary Syndrome (PCOS)?

    <p>AMH</p> Signup and view all the answers

    Prolactin levels are usually elevated in patients with Primary Ovarian Insufficiency (POI).

    <p>False</p> Signup and view all the answers

    Name two long-term consequences associated with obesity in females with PCOS.

    <p>Dyslipidemia and endometrial cancer</p> Signup and view all the answers

    In PCOS, the number of follicles is typically _____ while in Primary Ovarian Insufficiency, it is _____ .

    <p>increased; decreased</p> Signup and view all the answers

    Match the following conditions with their associated characteristics:

    <p>PCOS = Hirsutism POI = Hot flashes Both = Infertility</p> Signup and view all the answers

    Which of the following is NOT one of the Rotterdam criteria for diagnosing PCOS?

    <p>Elevated prolactin levels</p> Signup and view all the answers

    Lifestyle modification and weight loss can lead to spontaneous ovulation in some cases of PCOS.

    <p>True</p> Signup and view all the answers

    What is the primary indication for evaluating menstrual irregularities in young females?

    <p>Cycle length of 90 days or more after menarche, or irregular cycles persisting up to 3 years after menarche.</p> Signup and view all the answers

    The first-line management for menstrual irregularity in PCOS typically involves the use of _____ pills.

    <p>oral contraceptive</p> Signup and view all the answers

    Match the management approach with its corresponding feature of PCOS:

    <p>Menstrual irregularity = OCPs and Progesterone Infertility = Clomiphene citrate or IVF Hirsutism = Anti-androgens Insulin resistance = Metformin</p> Signup and view all the answers

    What is the minimum number of follicles required to meet the Rotterdam criteria for polycystic ovarian syndrome?

    <p>12</p> Signup and view all the answers

    Anovulation is associated with increased progesterone levels.

    <p>False</p> Signup and view all the answers

    What is the characteristic appearance of small unruptured follicles on ultrasound?

    <p>Necklace appearance</p> Signup and view all the answers

    The volume of the ovary should be _____ cc or more to meet certain criteria.

    <p>10</p> Signup and view all the answers

    Match the following descriptions with their related terms:

    <p>Anovulation = Infertility Multiple follicles = ≥ 12 Progesterone = ↓ levels Amenorrhea = 2° amenorrhea/oligomenorrhea</p> Signup and view all the answers

    What is the normal estrogen to androgen ratio in females without PCOS?

    <p>2:1</p> Signup and view all the answers

    Obesity is a defining feature of PCOS.

    <p>False</p> Signup and view all the answers

    What hormonal change can occur in obese PCOS patients that may lead to menstrual cycle irregularities?

    <p>elevated estrogen levels</p> Signup and view all the answers

    Dyslipidemia aggravates ______ resistance.

    <p>insulin</p> Signup and view all the answers

    Match the following potential complications with their descriptions:

    <p>Endometrial Cancer = Cancer of the uterine lining Ovarian Cancer = Possible cancer affecting the ovaries Non-alcoholic steatohepatitis = Liver disease due to fat buildup Dyslipidemia = High levels of fat in the blood</p> Signup and view all the answers

    What is one of the first steps to assess a diagnosed case of PCOS with symptoms like hirsutism and acne?

    <p>Testosterone levels</p> Signup and view all the answers

    Anovulation in PCOS is characterized by the presence of mature follicles.

    <p>False</p> Signup and view all the answers

    What is one consequence of insulin resistance in females with PCOS?

    <p>Obesity</p> Signup and view all the answers

    A reproductive age female with PCOS may require an endometrial biopsy if her endometrial thickness is greater than ______ mm.

    <p>12</p> Signup and view all the answers

    Match the following symptoms with their characteristics related to PCOS:

    <p>Hirsutism = Excessive hair growth Acne = Skin condition due to excess androgens Irregular cycles = Menstrual irregularities Dyslipidemia = Abnormal lipid levels</p> Signup and view all the answers

    Which of the following is a criterion for the provisional diagnosis of PCOS?

    <p>Polycystic appearance of ovaries</p> Signup and view all the answers

    What is the typical FSH:LH ratio in patients with PCOS?

    <p>1:2</p> Signup and view all the answers

    Menometrorrhagia is a diagnostic criterion for PCOS.

    <p>False</p> Signup and view all the answers

    Absence of LH surge does not affect ovulation.

    <p>False</p> Signup and view all the answers

    Name one short-term complication of PCOS.

    <p>Menstrual irregularities</p> Signup and view all the answers

    The hormone that is typically elevated in women with PCOS is _____.

    <p>LH</p> Signup and view all the answers

    What characterizes the hormonal profile in PCOS?

    <p>Increased testosterone and LH levels.</p> Signup and view all the answers

    In PCOS, theca cell hyperplasia contributes to increased _____ levels.

    <p>LH</p> Signup and view all the answers

    Match the following short-term complications with their associated symptoms:

    <p>Menstrual irregularities = Irregular or absent periods Hirsutism = Excessive hair growth Alopecia = Hair thinning or loss Infertility = Difficulty in conceiving</p> Signup and view all the answers

    Match the following hormones with their respective levels in PCOS:

    <p>FSH = Unchanged Testosterone = Increased LH = Increased Prolactin = Unchanged</p> Signup and view all the answers

    Which of the following features is associated with virilization?

    <p>Increased muscle mass</p> Signup and view all the answers

    Hirsutism can be indicated by a score of 6 on the modified Ferriman-Gallwey scoring system.

    <p>False</p> Signup and view all the answers

    Name one common site for hair growth associated with hirsutism.

    <p>Chin</p> Signup and view all the answers

    In virilization, a female may experience clitoromegaly, where the size of the clitoris is ≥ ___ cm.

    <p>1</p> Signup and view all the answers

    Match the following conditions with their associated characteristics:

    <p>Polycystic Ovary Syndrome (PCOS) = Mildly increased testosterone levels Congenital Adrenal Hyperplasia (CAH) = Markedly increased testosterone levels Androgen producing tumor of the ovary = Significant virilization features Idiopathic hirsutism = Normal androgen levels</p> Signup and view all the answers

    Which of the following is the most common cause of rapid onset hirsutism in young females?

    <p>Ovarian tumor</p> Signup and view all the answers

    Estrogen and progesterone help decrease androgen production in females.

    <p>True</p> Signup and view all the answers

    What is the primary medication used for the management of hirsutism?

    <p>OCP (Oral Contraceptive Pills)</p> Signup and view all the answers

    A confirmed diagnosis of CAH involves a 17 OH Progesterone level of ______ ng or higher.

    <p>800</p> Signup and view all the answers

    Match the following medications with their respective features:

    <p>Spironolactone = Anti-androgenic; contraindicated in pregnancy Cyproterone acetate = Hormonal treatment for hirsutism Flutamide = Anti-androgenic medication Ketoconazole = Can cause hirsutism as a side effect</p> Signup and view all the answers

    Study Notes

    Pathophysiology of PCOS

    • Polycystic Ovarian Syndrome (PCOS) is a group of symptoms with varying presentations and complex pathophysiology.

    • It used to be called Stein-Leventhal syndrome.

    Etiological Factors

    • Environmental Factors: Not fully understood.
    • Genetic Factors:
      • Complex genetic trait.
      • Chromosome no. 2.
      • Chromosome no. 9.
    • Lifestyle Factors: Can contribute to the condition.

    Excessive androgen production:

    • Ovaries are the main source of androgens.
    • Adrenal glands contribute a minor amount (increased DHEA-S).

    Pathophysiology:

    • Normal androgen levels in females: Not specified in the text.

    • Androgen levels in females with PCOS: Increased testosterone levels.

    • Defect in Folliculogenesis: Ovarian follicles fail to mature properly leading to anovulation.

    • Defect in Insulin action: Insulin resistance is common in PCOS.

    • Defect in gonadotropin secretion & action: Disruption in the secretion and action of gonadotropins (LH, FSH) contributes to anovulation.

    • Obesity: Present in 40-80% of patients with PCOS but not a defining feature.

    Rotterdam Criteria:

    • Increased androgen levels:

      • Biochemically: Elevated serum testosterone levels (Hyperandrogenemia).
      • Clinically: Evidence of hyperandrogenism such as hirsutism.

    • Ovulatory dysfunction: Secondary amenorrhea or oligomenorrhea (irregular menstrual cycles).

    • Polycystic appearance of ovaries:

      • On ultrasound (USG): 12 or more follicles, 2-9 mm in size, in one or both ovaries.
      • Ovarian volume ≥ 10 cc.

    • Any two of the above criteria: Provisional diagnosis of PCOS.

    Consequences of PCOS:

    • Short-Term Complications:

      • Menstrual irregularities.
      • Infertility.
      • Hirsutism.
      • Alopecia.
      • Insulin resistance.

    • Long-Term Consequences:

      • Metabolic: Dyslipidemia, diabetes, heart disease.
      • Endocrine: Endometrial cancer (due to increased estrogen in obese females).
      • Other: Sleep apnea, ovarian cancer, non-alcoholic steatohepatitis (NASH) (due to obesity).

    Obstetric Complications:

    • Infertility, which is often reversible with treatment.

    • Increased risk of miscarriage due to low progesterone levels.

    • Gestational diabetes due to insulin resistance.

    • Pregnancy-induced hypertension (PIH).

    • Stillbirth.

    • Psychological: Anxiety and depression.

    • Metabolic: Metabolic syndrome.

    HAIRAN Syndrome:

    • Hyper Androgenism
    • Insulin Resistance
    • Acanthosis Nigricans

    Hormonal Profile in PCOS:

    • Unchanged: Follicle-stimulating hormone (FSH), estradiol, prolactin and Thyroid-stimulating hormone (TSH).

    • Increased: Serum testosterone, DHEA-S, low-density lipoprotein (LDL), anti-müllerian hormone (AMH) and luteinizing hormone (LH) – especially in obese females.

    • Affected by androgens and insulin: High-density lipoprotein (HDL), serum progesterone, sex hormone-binding globulin (SHBG).

    Anovulation in PCOS:

    • Folliculotoxicity of androgens: Androgens damage developing follicles.

    • Absence of LH surge: Prevents ovulation.

    Management of PCOS:

    • First Line: Lifestyle modification, including weight loss, can improve symptoms and lead to spontaneous ovulation in 5-10% of cases.

    • Hyperprolactinemia: Should be ruled out in all patients with PCOS as it can cause menstrual irregularities.

    Management of Menstrual Irregularities and Hirsutism:

    • Menstrual Irregularities:

      • Pubertal/Young Females:

        • Irregular cycles due to anovulation – common until 3 years after menarche.
        • Cycle length: 21-45 days.
        • ≥ 90 days cycle length or onset of menstruation 3 years after menarche needs evaluation.

      • First Line Management:

        • Oral contraceptive pills (OCPs) (very low-dose) – ethinyl estradiol ≤ 20 mcg.
        • Progesterone (3rd/4th generation) – MALA-D/MALA-N may be used.

    • Hirsutism:

      • First Line Management:

        • Oral contraceptive pills (OCPs) – low dose and 3rd/4th generation progesterone.
        • Duration: 6 months.
        • Mechanism of Action:
          • Estrogen and progesterone suppress LH and FSH production = decreased androgen production.
          • Estrogen increases sex hormone binding globulin (SHBG) = decreased free testosterone.

      • If OCPs fail: Add spironolactone.

    Noteworthy points:

    • Spironolactone: Anti-androgenic medication. Use is contraindicated in pregnancy (potential for ambiguous genitalia in male fetus).

    • Other drugs used to manage hirsutism:

      • Cyproterone acetate.
      • Flutamide.
      • Finasteride.
      • Metformin (may be slightly effective).
      • Eflornithine (topical medication).
      • Last resort: Continuous GnRH and androgen.

    • Ketoconazole: Can cause hirsutism as a side effect.

    • Laser Hair Removal: Additional modality for managing hirsutism.

    Hirsutism vs. Virilization:

    • Hirsutism: Excessive growth of thick, coarse terminal hair in a male pattern. Common sites: lips, chin, periareolar area, chest.
    • Virilization: Female acquires male sexual characteristics.
    Feature Hirsutism Virilization
    Description Growth of thick, coarse, terminal hair in male pattern. Female acquires male secondary sexual characteristics.
    Features Alopecia (male pattern baldness), scarring acne. Hirsutism, deepening of voice, breast atrophy, increased muscle mass, clitoromegaly (size ≥ 1 cm).
    Testosterone levels Mildly increased. Markedly increased.
    Conditions - PCOS, - Some cases of late onset Congenital Adrenal Hyperplasia (CAH), - Idiopathic hirsutism - Androgen producing tumor of ovary, - Most cases of CAH.
    Scoring System Modified Ferriman-Gallwey (9 sites, each scored 0-4, score ≥ 8 = hirsutism) Prader score.
    Investigations 200 ng: Androgen secreting ovarian tumor (Virilization +), CAH -

    Defect in Gonadotropin Secretion:

    • PCOS: Increased pulse frequency of GnRH, leading to increased LH secretion by the pituitary gland. Increased LH levels throughout the cycle.

    • Theca cell hyperplasia: Contributes to increased LH levels.

    • FSH: LH Ratio:

      • PCOS: 1:2 or 1:3.
      • Normal: Around 1:1.

    • Absence of LH surge: Leads to anovulation.

    Note:

    • Most common cause of hirsutism in young females: PCOS.

    • Most common cause of rapid onset hirsutism in young females: Ovarian tumor.

    • Distinguishing PCOS from late-onset CAH:

      • 17-OH Progesterone levels (screening test for CAH):
        • ≥ 800 ng: Confirms CAH.
      • ACTH Stimulation test (diagnostic).

    • American and European Societies criteria for PCOS: ≥ 20 follicles, 2-9 mm in size, on ultrasound.

    • Ovaries can appear normal in PCOS.

    Additional Notes:

    • It is crucial to evaluate LH and FSH levels on day 2/3 of the menstrual cycle to accurately assess hormonal profiles.

    • Menometrorrhagia (irregular bleeding): Can occur in obese PCOS patients due to elevated estrogen levels.

    • Endometrial biopsy is indicated in reproductive-age females with PCOS and an endometrial thickness ≥ 12 mm.

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    Description

    Explore the complex pathophysiology of Polycystic Ovarian Syndrome (PCOS) in this quiz. Learn about the etiological factors, including genetic, environmental, and lifestyle influences. Understand the hormonal imbalances and defects in folliculogenesis associated with PCOS.

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