Polycystic Ovary Syndrome (PCOS) Overview
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Questions and Answers

What are the main characteristics of polycystic ovarian syndrome (PCOS)?

PCOS is characterized by ovarian dysfunction, hyperandrogenism, and polycystic ovary morphology.

How does insulin resistance relate to PCOS?

Insulin resistance is common in both obese and non-obese patients with PCOS and contributes to the syndrome's pathophysiology.

What role do environmental factors play in the development of PCOS?

Environmental factors such as diet and exercise interact with genetic elements to influence the onset and progression of PCOS.

What is the significance of ovarian morphology in diagnosing PCOS?

<p>Polycystic ovary morphology on ultrasound is a classical indicator used for diagnosing PCOS.</p> Signup and view all the answers

What are common clinical manifestations of PCOS?

<p>Common manifestations include menstrual irregularities, hirsutism, obesity, and elevated serum LH levels.</p> Signup and view all the answers

Discuss the prevalence of PCOS in different populations.

<p>PCOS affects around 5-10% of reproductive-age women, with higher prevalence and severity observed in certain ethnic groups like South Asians.</p> Signup and view all the answers

What hormonal imbalances are typically seen in women with PCOS?

<p>Women with PCOS often exhibit an imbalance characterized by increased ovarian androgens and elevated levels of LH.</p> Signup and view all the answers

How does genetic predisposition affect the risk of developing PCOS?

<p>PCOS appears to have a genetic component, with an inheritance pattern that suggests an autosomal dominant trait.</p> Signup and view all the answers

What are some common clinical features associated with PCOM?

<p>Common features include oligomenorrhoea, hirsutism, obesity, and recurrent miscarriages.</p> Signup and view all the answers

How does increased androgen affect women with PCOM?

<p>Increased androgen can lead to hirsutism, acne, and irregular menstrual periods.</p> Signup and view all the answers

What role does obesity play in the diagnosis of PCOM?

<p>Obesity is present in at least 40% of PCOM patients and is a significant risk factor.</p> Signup and view all the answers

Describe the ultrasound findings that may suggest a diagnosis of PCOS.

<p>Ultrasound may show more than 12 follicles per ovary measuring 2-9 mm and/or increased ovarian volume over 10 mL.</p> Signup and view all the answers

What are the common signs of hyperandrogenism in women with PCOM?

<p>Common signs include excess facial hair growth, acne, and androgenic alopecia.</p> Signup and view all the answers

What methods are used in the diagnosis of PCOM?

<p>Diagnosis involves patient history, physical examination, and investigations like ultrasound and hormonal evaluation.</p> Signup and view all the answers

What is the prevalence of polycystic ovaries in the general population?

<p>Polycystic ovaries are estimated to be present in 20-33% of the general population.</p> Signup and view all the answers

How does chronic anovulation relate to PCOM?

<p>Chronic anovulation leads to menstrual cycle disturbances, which is a key feature of PCOM.</p> Signup and view all the answers

What is the initial approach when starting parenteral gonadotropin therapy for patients with anovulatory infertility?

<p>The initial approach involves starting with very low doses of gonadotropins while carefully monitoring follicular development by ultrasound scans.</p> Signup and view all the answers

What is one major advantage of laparoscopic ovarian diathermy compared to other treatment options for anovulatory infertility?

<p>Laparoscopic ovarian diathermy is free of the risks of multiple pregnancy and ovarian hyperstimulation, and it does not require intensive ultrasound monitoring.</p> Signup and view all the answers

What serious condition can result from ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovary syndrome?

<p>Ovarian hyperstimulation syndrome can lead to abdominal distension, discomfort, and can even result in potentially fatal complications like thromboembolism.</p> Signup and view all the answers

How does metformin assist women with polycystic ovary syndrome experiencing anovulatory infertility?

<p>Metformin improves insulin sensitivity, decreases insulin secretion, and can restore menstrual cyclicity and fertility in women with PCOS.</p> Signup and view all the answers

Why is monitoring important during gonadotropin therapy, especially for women with polycystic ovary syndrome?

<p>Monitoring is essential to avoid ovarian hyperstimulation syndrome, which can occur if too many follicles are stimulated.</p> Signup and view all the answers

What are the baseline investigations recommended before starting metformin therapy in anovulatory women with PCOS?

<p>Baseline investigations include an oral glucose tolerance test (GTT), full blood count (FBC), urea and electrolytes (U&amp;E), and liver function tests (LFTs).</p> Signup and view all the answers

What is the consequence of having multiple follicles stimulated during gonadotropin therapy?

<p>Stimulating too many follicles can lead to ovarian hyperstimulation syndrome, which may cause serious health complications.</p> Signup and view all the answers

Why has wedge resection of the ovaries fallen out of favor as a treatment option?

<p>Wedge resection is no longer commonly used because it can cause extensive peri-ovarian and tubal adhesions.</p> Signup and view all the answers

What is the purpose of using eflornithine in the treatment of hirsutism?

<p>Eflornithine inhibits the enzyme ornithine decarboxylase in hair follicles, slowing hair growth.</p> Signup and view all the answers

What first-line therapy is traditionally recommended for treating hirsutism in women?

<p>Dianette, which contains ethinyloestradiol and cyproterone acetate, is the first-line therapy.</p> Signup and view all the answers

Why is it important for women of reproductive age to use adequate contraception when taking antiandrogens?

<p>Antiandrogens may disturb the genital development of a male fetus due to transplacental passage.</p> Signup and view all the answers

How can the gastrointestinal side effects of metformin be minimized?

<p>Taking metformin just before food and gradually increasing the dose can reduce gastrointestinal side effects.</p> Signup and view all the answers

What is the role of spironolactone in managing hirsutism in women?

<p>Spironolactone is used as an antiandrogen with diuretic properties for women who cannot take the COCP.</p> Signup and view all the answers

What are the three features required for a diagnosis of polycystic ovary syndrome (PCOS)?

<p>Oligomenorrhoea/amenorrhoea, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound.</p> Signup and view all the answers

How does obesity impact the symptoms and endocrine profile in women with PCOS?

<p>Obesity worsens both symptomatology and the endocrine profile in women with PCOS.</p> Signup and view all the answers

What role do androgens, such as testosterone and androstenedione, play in the diagnosis of PCOS?

<p>Elevated levels of androgens, like testosterone and androstenedione, indicate hyperandrogenism, a key feature of PCOS.</p> Signup and view all the answers

What long-term health risks are associated with having PCOS?

<p>Women with PCOS face an increased risk of diabetes, cardiovascular disease, endometrial carcinoma, and breast cancer.</p> Signup and view all the answers

What is the recommended lifestyle intervention for obese women with PCOS?

<p>Lifestyle interventions should include dietary modifications and increased exercise to promote weight loss.</p> Signup and view all the answers

Why is a glucose tolerance test (GTT) performed on obese patients with PCOS?

<p>A GTT is performed to assess impaired glucose tolerance in obese patients with a BMI &gt;30 kg/m².</p> Signup and view all the answers

What medications are currently licensed in the UK for weight loss in obese patients with PCOS?

<p>Sibutramine and orlistat are the two licensed weight-loss medications in the UK.</p> Signup and view all the answers

How can weight loss impact the reproductive outcomes for women with PCOS?

<p>Weight loss improves the likelihood of ovulation and leads to healthier pregnancy outcomes.</p> Signup and view all the answers

Study Notes

Polycystic Ovary Syndrome (PCOS)

  • PCOS is a common endocrine disorder affecting women of reproductive age.
  • It affects roughly 5-10% of women of reproductive age globally.
  • Prevalence is higher in certain ethnic groups, including South Asians, who often experience more severe symptoms.
  • PCOS is defined by ovarian dysfunction, hyperandrogenism, and polycystic ovary morphology.

The Clinical Picture of PCOS

  • Patients with PCOS experience menstrual irregularities.
  • Hyperandrogenism symptoms are common, including hirsutism (excess hair).
  • Obesity is prevalent in PCOS patients (at least 40%).
  • Recurrent miscarriage affects around 50-60% of women with PCOS.
  • Acanthosis nigricans is a skin condition characterized by velvety dark patches.
  • Acanthosis nigricans can present in areas like the axillae (armpits).
  • Acanthosis nigricans can be asymptomatic.

The Pathophysiology and Causes of PCOS

  • The exact origin of PCOS is unknown, but it likely involves a complex interplay of genetic and environmental factors.
  • Lifestyle, diet, and exercise play significant roles in the development of PCOS.
  • Genetics, particularly autosomal dominant inheritance patterns, are implicated in PCOS.
  • Several factors contribute to the development of PCOS, including:
    • Dysfunction in ovarian function, leading to increased production of androgens.
    • Dysfunction in hypothalamic function, resulting in elevated LH secretion, which further stimulates androgen production in the theca cells.
    • Insulin resistance, a common feature in both obese and non-obese PCOS patients.

Diagnosis of PCOS

  • Diagnosis relies on a combination of clinical history, physical examination, and investigations.
  • Essential information gathered during patient history includes:
    • Hirsutism, acne, body weight changes.
    • Menstrual history, including irregularities.
    • History of miscarriages.
    • Family history of hirsutism and menstrual dysfunction.
  • Physical examination should assess:
    • Body build, weight, and hair distribution.
    • Degree of hirsutism, acne, and androgenic alopecia.
  • Investigations include:
    • Ultrasound: For identifying polycystic ovaries.
    • Hormonal level assessment.
    • Evaluation of patient's metabolic status.
  • Ultrasound findings suggestive of PCOS include:
    • More than 12 follicles each ovary, ranging from 2-9 mm in size.
    • Increased ovarian volume exceeding 10 mL.
  • Polycystic ovaries are a common finding identified by ultrasound or other pelvic imaging, with prevalence estimates ranging 20-33% in the general population.
  • Serum endocrinology examination reveals:
    • Elevated fasting insulin (not routinely measured, insulin resistance or glucose intolerance is assessed by GTT).
    • Elevated androgens, specifically testosterone and androstenedione.
    • Elevated luteinizing hormone (LH) with normal follicle-stimulating hormone (FSH).
    • Decreased sex hormone-binding globulin (SHBG), leading to elevated 'free androgen index'.
    • Elevated estradiol and estrone (not routinely measured due to wide variability).
    • Elevated prolactin.
  • A diagnosis of PCOS is confirmed when a patient exhibits two of the following three features:
    • Oligomenorrhoea/amenorrhoea.
    • Clinical or biochemical hyperandrogenism.
    • Polycystic ovaries identified by ultrasound.

Potential Long-Term Health Consequences of PCOS

  • Evidence suggests that women with PCOS are at increased risk of developing diabetes and cardiovascular disease in the long term.
  • Possible late sequelae of PCOS include:
    • Diabetes mellitus.
    • Dyslipidaemia.
    • Hypertension and cardiovascular disease.
    • Endometrial carcinoma.
    • Breast cancer.

Management of PCOS

  • Management strategies are tailored to the individual patient's specific concerns.
  • Obesity:
    • Weight loss is crucial for managing PCOS symptoms, improving endocrine profile, and increasing the likelihood of ovulation and a healthy pregnancy.
    • Obese women (BMI > 30 kg/m2) should strive to lose weight.
    • Dietary changes focus on reducing carbohydrate intake and avoiding fatty foods.
    • Metformin does not demonstrate a direct benefit in weight reduction.
    • If BMI exceeds 30 kg/m2, an oral glucose tolerance test (GTT) is recommended.
    • Weight-loss medications, such as sibutramine and orlistat, may be considered for individuals who struggle to achieve adequate weight loss through diet and exercise alone.
  • Anovulatory Infertility:
    • Parenteral gonadotropin therapy is an option for patients resistant to antioestrogens.
    • Given the increased sensitivity of polycystic ovaries to exogenous hormones, low-dose gonadotropin therapy is essential.
    • Follicular development requires careful monitoring via ultrasound scans.
  • Ovarian Diathermy:
    • Laparoscopic ovarian diathermy offers a treatment option free from the risks associated with multiple pregnancy or ovarian hyperstimulation syndrome.
    • It does not require intensive ultrasound monitoring.
  • Wedge Resection:
    • This procedure has largely been discontinued due to potential complications, including extensive peri-ovarian and tubal adhesions.

Ovarian Hyperstimulation Syndrome (OHSS)

  • OHSS is a potential complication associated with gonadotropin therapy, particularly in women with PCOS.
  • It occurs when an excessive number of follicles (more than 10 mm) are stimulated, leading to:
    • Abdominal distension.
    • Discomfort.
    • Nausea, vomiting.
    • Respiratory difficulties.
  • The underlying mechanism of OHSS is believed to involve activation of the ovarian renin-angiotensin pathway and excessive VEGF secretion.
  • Fluid accumulation in the ascites, pleural effusion, and pericardial effusion contributes to the severity of OHSS.
  • The haemoconcentration associated with OHSS raises the risk of thromboembolism.
  • OHSS is exacerbated during pregnancy, as hCG from the placenta further stimulates the ovaries.
  • Hospitalization may be necessary for intravenous fluid administration and heparin to prevent dehydration and thromboembolism.
  • Although rare, OHSS can be life-threatening, but proper monitoring of gonadotropin therapy can help prevent it.

Treatment of PCOS: Insulin-Sensitizing Agents and Metformin

  • Metformin, a biguanide, inhibits hepatic glucose production and increases peripheral tissue insulin sensitivity.
  • It helps to decrease insulin secretion.
  • Studies have demonstrated that metformin can ameliorate hyperandrogenism and abnormalities in gonadotropin secretion in PCOS patients.
  • Metformin can restore menstrual cyclicity and increase fertility in individuals with PCOS.
  • Metformin therapy can be initiated after appropriate screening and counseling on diet, lifestyle, and exercise for anovulatory women with PCOS who have not achieved pregnancy.
  • The standard dosage is 850 mg twice daily or 500 mg three times daily.
  • Baseline assessments should include:
    • Oral glucose tolerance test (GTT).
    • Complete blood count (FBC).
    • Urea and electrolytes (U&E).
    • Liver function tests (LFTs).
  • Side effects are primarily gastrointestinal, including anorexia, nausea, flatulence, and diarrhea.
  • These side effects can be minimized by taking metformin before meals and gradually increasing the dosage starting from 850 mg once daily to 850 mg twice daily after a week.

Management of Hyperandrogenism and Hirsutism

  • Drug treatments for hirsutism may take several months (6-9 or more) to show noticeable improvement.
  • Physical methods including electrolysis, waxing, and bleaching can provide immediate relief while waiting for medication to take effect.
  • Laser and photothermolysis techniques are more expensive but may have a longer-lasting effect.
  • Eflornithine is a topical treatment option that inhibits the enzyme ornithine decarboxylase within hair follicles.
  • Eflornithine may be a suitable option for individuals who want to avoid hormonal treatments or can be used alongside hormonal therapies.
  • Eflornithine can cause skin thinning, so applying high-factor sunscreen is advised during sun exposure.
  • Medical regimens aim to stop further progression of hirsutism and reduce hair growth.
  • Adequate contraception is essential for women of reproductive age.
  • The transplacental passage of antiandrogens can interfere with the genital development of a male fetus.
  • Treatment options for hyperandrogenism and hirsutism include:
    • Dianette: A combined oral contraceptive pill containing ethinylestradiol (30 μg) and cyproterone acetate (2 mg).
    • Spironolactone: A weak diuretic with antiandrogenic properties. It can be used in women for whom combined oral contraceptive pills are contraindicated, with a daily dosage ranging from 25-100 mg.
    • Yasmin: A combined oral contraceptive pill containing drosperinone, a derivative of spironolactone, which can be beneficial for women with PCOS.
    • Other antiandrogens: Ketoconazole, finasteride, and flutamide have been investigated but are not extensively used in the UK for treating hirsutism in women due to their adverse side effects. They have not proven to be more effective than cyproterone acetate.

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This quiz explores Polycystic Ovary Syndrome (PCOS), a common condition affecting women of reproductive age. You will learn about its prevalence, clinical symptoms, and potential causes, including its effects on different ethnic groups. Understand the complexities of this endocrine disorder and its impact on women's health.

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