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Questions and Answers
What is one of the main sources of excessive androgen production in females?
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.
PCOS is also known as Stein-Leventhal syndrome.
True (A)
Name one genetic factor associated with PCOS.
Name one genetic factor associated with PCOS.
Chromosome no. 2
Excessive production of androgens in PCOS can lead to defects in ______ and ______.
Excessive production of androgens in PCOS can lead to defects in ______ and ______.
Match the following factors with their categories related to PCOS:
Match the following factors with their categories related to PCOS:
Which hormone level is typically elevated in a patient with Polycystic Ovary Syndrome (PCOS)?
Which hormone level is typically elevated in a patient with Polycystic Ovary Syndrome (PCOS)?
Prolactin levels are usually elevated in patients with Primary Ovarian Insufficiency (POI).
Prolactin levels are usually elevated in patients with Primary Ovarian Insufficiency (POI).
Name two long-term consequences associated with obesity in females with PCOS.
Name two long-term consequences associated with obesity in females with PCOS.
In PCOS, the number of follicles is typically _____ while in Primary Ovarian Insufficiency, it is _____ .
In PCOS, the number of follicles is typically _____ while in Primary Ovarian Insufficiency, it is _____ .
Match the following conditions with their associated characteristics:
Match the following conditions with their associated characteristics:
Which of the following is NOT one of the Rotterdam criteria for diagnosing PCOS?
Which of the following is NOT one of the Rotterdam criteria for diagnosing PCOS?
Lifestyle modification and weight loss can lead to spontaneous ovulation in some cases of PCOS.
Lifestyle modification and weight loss can lead to spontaneous ovulation in some cases of PCOS.
What is the primary indication for evaluating menstrual irregularities in young females?
What is the primary indication for evaluating menstrual irregularities in young females?
The first-line management for menstrual irregularity in PCOS typically involves the use of _____ pills.
The first-line management for menstrual irregularity in PCOS typically involves the use of _____ pills.
Match the management approach with its corresponding feature of PCOS:
Match the management approach with its corresponding feature of PCOS:
What is the minimum number of follicles required to meet the Rotterdam criteria for polycystic ovarian syndrome?
What is the minimum number of follicles required to meet the Rotterdam criteria for polycystic ovarian syndrome?
Anovulation is associated with increased progesterone levels.
Anovulation is associated with increased progesterone levels.
What is the characteristic appearance of small unruptured follicles on ultrasound?
What is the characteristic appearance of small unruptured follicles on ultrasound?
The volume of the ovary should be _____ cc or more to meet certain criteria.
The volume of the ovary should be _____ cc or more to meet certain criteria.
Match the following descriptions with their related terms:
Match the following descriptions with their related terms:
What is the normal estrogen to androgen ratio in females without PCOS?
What is the normal estrogen to androgen ratio in females without PCOS?
Obesity is a defining feature of PCOS.
Obesity is a defining feature of PCOS.
What hormonal change can occur in obese PCOS patients that may lead to menstrual cycle irregularities?
What hormonal change can occur in obese PCOS patients that may lead to menstrual cycle irregularities?
Dyslipidemia aggravates ______ resistance.
Dyslipidemia aggravates ______ resistance.
Match the following potential complications with their descriptions:
Match the following potential complications with their descriptions:
What is one of the first steps to assess a diagnosed case of PCOS with symptoms like hirsutism and acne?
What is one of the first steps to assess a diagnosed case of PCOS with symptoms like hirsutism and acne?
Anovulation in PCOS is characterized by the presence of mature follicles.
Anovulation in PCOS is characterized by the presence of mature follicles.
What is one consequence of insulin resistance in females with PCOS?
What is one consequence of insulin resistance in females with PCOS?
A reproductive age female with PCOS may require an endometrial biopsy if her endometrial thickness is greater than ______ mm.
A reproductive age female with PCOS may require an endometrial biopsy if her endometrial thickness is greater than ______ mm.
Match the following symptoms with their characteristics related to PCOS:
Match the following symptoms with their characteristics related to PCOS:
Which of the following is a criterion for the provisional diagnosis of PCOS?
Which of the following is a criterion for the provisional diagnosis of PCOS?
What is the typical FSH:LH ratio in patients with PCOS?
What is the typical FSH:LH ratio in patients with PCOS?
Menometrorrhagia is a diagnostic criterion for PCOS.
Menometrorrhagia is a diagnostic criterion for PCOS.
Absence of LH surge does not affect ovulation.
Absence of LH surge does not affect ovulation.
Name one short-term complication of PCOS.
Name one short-term complication of PCOS.
The hormone that is typically elevated in women with PCOS is _____.
The hormone that is typically elevated in women with PCOS is _____.
What characterizes the hormonal profile in PCOS?
What characterizes the hormonal profile in PCOS?
In PCOS, theca cell hyperplasia contributes to increased _____ levels.
In PCOS, theca cell hyperplasia contributes to increased _____ levels.
Match the following short-term complications with their associated symptoms:
Match the following short-term complications with their associated symptoms:
Match the following hormones with their respective levels in PCOS:
Match the following hormones with their respective levels in PCOS:
Which of the following features is associated with virilization?
Which of the following features is associated with virilization?
Hirsutism can be indicated by a score of 6 on the modified Ferriman-Gallwey scoring system.
Hirsutism can be indicated by a score of 6 on the modified Ferriman-Gallwey scoring system.
Name one common site for hair growth associated with hirsutism.
Name one common site for hair growth associated with hirsutism.
In virilization, a female may experience clitoromegaly, where the size of the clitoris is ≥ ___ cm.
In virilization, a female may experience clitoromegaly, where the size of the clitoris is ≥ ___ cm.
Match the following conditions with their associated characteristics:
Match the following conditions with their associated characteristics:
Which of the following is the most common cause of rapid onset hirsutism in young females?
Which of the following is the most common cause of rapid onset hirsutism in young females?
Estrogen and progesterone help decrease androgen production in females.
Estrogen and progesterone help decrease androgen production in females.
What is the primary medication used for the management of hirsutism?
What is the primary medication used for the management of hirsutism?
A confirmed diagnosis of CAH involves a 17 OH Progesterone level of ______ ng or higher.
A confirmed diagnosis of CAH involves a 17 OH Progesterone level of ______ ng or higher.
Match the following medications with their respective features:
Match the following medications with their respective features:
Study Notes
Pathophysiology of PCOS
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Polycystic Ovarian Syndrome (PCOS) is a group of symptoms with varying presentations and complex pathophysiology.
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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:
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Normal androgen levels in females: Not specified in the text.
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Androgen levels in females with PCOS: Increased testosterone levels.
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Defect in Folliculogenesis: Ovarian follicles fail to mature properly leading to anovulation.
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Defect in Insulin action: Insulin resistance is common in PCOS.
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Defect in gonadotropin secretion & action: Disruption in the secretion and action of gonadotropins (LH, FSH) contributes to anovulation.
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Obesity: Present in 40-80% of patients with PCOS but not a defining feature.
Rotterdam Criteria:
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Increased androgen levels:
- Biochemically: Elevated serum testosterone levels (Hyperandrogenemia).
- Clinically: Evidence of hyperandrogenism such as hirsutism.
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Ovulatory dysfunction: Secondary amenorrhea or oligomenorrhea (irregular menstrual cycles).
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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.
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Any two of the above criteria: Provisional diagnosis of PCOS.
Consequences of PCOS:
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Short-Term Complications:
- Menstrual irregularities.
- Infertility.
- Hirsutism.
- Alopecia.
- Insulin resistance.
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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:
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Infertility, which is often reversible with treatment.
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Increased risk of miscarriage due to low progesterone levels.
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Gestational diabetes due to insulin resistance.
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Pregnancy-induced hypertension (PIH).
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Stillbirth.
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Psychological: Anxiety and depression.
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Metabolic: Metabolic syndrome.
HAIRAN Syndrome:
- Hyper Androgenism
- Insulin Resistance
- Acanthosis Nigricans
Hormonal Profile in PCOS:
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Unchanged: Follicle-stimulating hormone (FSH), estradiol, prolactin and Thyroid-stimulating hormone (TSH).
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Increased: Serum testosterone, DHEA-S, low-density lipoprotein (LDL), anti-müllerian hormone (AMH) and luteinizing hormone (LH) – especially in obese females.
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Affected by androgens and insulin: High-density lipoprotein (HDL), serum progesterone, sex hormone-binding globulin (SHBG).
Anovulation in PCOS:
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Folliculotoxicity of androgens: Androgens damage developing follicles.
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Absence of LH surge: Prevents ovulation.
Management of PCOS:
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First Line: Lifestyle modification, including weight loss, can improve symptoms and lead to spontaneous ovulation in 5-10% of cases.
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Hyperprolactinemia: Should be ruled out in all patients with PCOS as it can cause menstrual irregularities.
Management of Menstrual Irregularities and Hirsutism:
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Menstrual Irregularities:
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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.
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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.
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Hirsutism:
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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.
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If OCPs fail: Add spironolactone.
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Noteworthy points:
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Spironolactone: Anti-androgenic medication. Use is contraindicated in pregnancy (potential for ambiguous genitalia in male fetus).
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Other drugs used to manage hirsutism:
- Cyproterone acetate.
- Flutamide.
- Finasteride.
- Metformin (may be slightly effective).
- Eflornithine (topical medication).
- Last resort: Continuous GnRH and androgen.
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Ketoconazole: Can cause hirsutism as a side effect.
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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:
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PCOS: Increased pulse frequency of GnRH, leading to increased LH secretion by the pituitary gland. Increased LH levels throughout the cycle.
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Theca cell hyperplasia: Contributes to increased LH levels.
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FSH: LH Ratio:
- PCOS: 1:2 or 1:3.
- Normal: Around 1:1.
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Absence of LH surge: Leads to anovulation.
Note:
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Most common cause of hirsutism in young females: PCOS.
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Most common cause of rapid onset hirsutism in young females: Ovarian tumor.
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Distinguishing PCOS from late-onset CAH:
- 17-OH Progesterone levels (screening test for CAH):
- ≥ 800 ng: Confirms CAH.
- ACTH Stimulation test (diagnostic).
- 17-OH Progesterone levels (screening test for CAH):
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American and European Societies criteria for PCOS: ≥ 20 follicles, 2-9 mm in size, on ultrasound.
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Ovaries can appear normal in PCOS.
Additional Notes:
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It is crucial to evaluate LH and FSH levels on day 2/3 of the menstrual cycle to accurately assess hormonal profiles.
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Menometrorrhagia (irregular bleeding): Can occur in obese PCOS patients due to elevated estrogen levels.
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Endometrial biopsy is indicated in reproductive-age females with PCOS and an endometrial thickness ≥ 12 mm.
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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.
