Podcast
Questions and Answers
What are the common features commonly seen in women with polycystic ovary syndrome?
What are the common features commonly seen in women with polycystic ovary syndrome?
hirsutism, acne, and scalp hair loss
What are some methods used in the diagnosis of polycystic ovary syndrome (PCOS)?
What are some methods used in the diagnosis of polycystic ovary syndrome (PCOS)?
Polycystic ovaries are present in 75% of women with PCOS, but are not seen in other conditions.
Polycystic ovaries are present in 75% of women with PCOS, but are not seen in other conditions.
False
Hyper-androgenaemia is present in __% to __% of women with PCOS.
Hyper-androgenaemia is present in __% to __% of women with PCOS.
Signup and view all the answers
What is the 1st test to order in the diagnosis of PCOS?
What is the 1st test to order in the diagnosis of PCOS?
Signup and view all the answers
Which test is performed to exclude hyperprolactinaemia in PCOS?
Which test is performed to exclude hyperprolactinaemia in PCOS?
Signup and view all the answers
High levels of bisphenol A observed in PCOS women are not linked to insulin resistance and hyperandrogenism.
High levels of bisphenol A observed in PCOS women are not linked to insulin resistance and hyperandrogenism.
Signup and view all the answers
Pelvic ultrasound may show ___ follicles in each ovary in PCOS.
Pelvic ultrasound may show ___ follicles in each ovary in PCOS.
Signup and view all the answers
What is the leading cause of infertility and pregnancy complications in women?
What is the leading cause of infertility and pregnancy complications in women?
Signup and view all the answers
PCOS affects about 6% of women of reproductive age in the US and Europe.
PCOS affects about 6% of women of reproductive age in the US and Europe.
Signup and view all the answers
What is the recommendation by the American College of Obstetricians and Gynecologists regarding DHEAS evaluation in PCOS cases?
What is the recommendation by the American College of Obstetricians and Gynecologists regarding DHEAS evaluation in PCOS cases?
Signup and view all the answers
What are the main treatment goals for PCOS?
What are the main treatment goals for PCOS?
Signup and view all the answers
Which hormones should be measured in all women to exclude disorders that may resemble PCOS?
Which hormones should be measured in all women to exclude disorders that may resemble PCOS?
Signup and view all the answers
PCOS includes symptoms of hyper-androgenism, presence of hyper-androgenaemia, oligo-/anovulation, and polycystic ovarian morphology on ________.
PCOS includes symptoms of hyper-androgenism, presence of hyper-androgenaemia, oligo-/anovulation, and polycystic ovarian morphology on ________.
Signup and view all the answers
Low-level prolactin elevations (20-30 ng/mL) are common in PCOS with associated galactorrhoea or pituitary adenoma on imaging.
Low-level prolactin elevations (20-30 ng/mL) are common in PCOS with associated galactorrhoea or pituitary adenoma on imaging.
Signup and view all the answers
Match the PCOS classification with their characteristics:
Match the PCOS classification with their characteristics:
Signup and view all the answers
Insulin resistance may be suggested by fasting insulin levels >69 to 104 pmol/L (10-15 micro-units/mL) indicating ____.
Insulin resistance may be suggested by fasting insulin levels >69 to 104 pmol/L (10-15 micro-units/mL) indicating ____.
Signup and view all the answers
What imaging technique provides higher-resolution images of the ovaries in polycystic ovary syndrome?
What imaging technique provides higher-resolution images of the ovaries in polycystic ovary syndrome?
Signup and view all the answers
Which test may be considered as an alternative to pelvic ultrasound in adults for diagnosing polycystic ovary syndrome?
Which test may be considered as an alternative to pelvic ultrasound in adults for diagnosing polycystic ovary syndrome?
Signup and view all the answers
An LH/FSH ratio greater than 3 suggests polycystic ovary syndrome.
An LH/FSH ratio greater than 3 suggests polycystic ovary syndrome.
Signup and view all the answers
A fasting glucose level between $5.6$ and $6.9$ mmol/L indicates ____________.
A fasting glucose level between $5.6$ and $6.9$ mmol/L indicates ____________.
Signup and view all the answers
According to the BMJ Best Practice topic, what is recommended as the first-line option for pharmacological treatment of infertility in women with PCOS?
According to the BMJ Best Practice topic, what is recommended as the first-line option for pharmacological treatment of infertility in women with PCOS?
Signup and view all the answers
How does Clomifene work in the treatment of infertility for women with PCOS?
How does Clomifene work in the treatment of infertility for women with PCOS?
Signup and view all the answers
In case three treatment cycles of clomifene have failed, it is reasonable to add _____ according to the BMJ Best Practice topic.
In case three treatment cycles of clomifene have failed, it is reasonable to add _____ according to the BMJ Best Practice topic.
Signup and view all the answers
What might reduce the risk of ovarian hyperstimulation syndrome when used in combination with gonadotrophins?
What might reduce the risk of ovarian hyperstimulation syndrome when used in combination with gonadotrophins?
Signup and view all the answers
In cases of anovulatory PCOS resistant to clomifene, what was found to have lower live birth rates compared to laparoscopic ovarian drilling?
In cases of anovulatory PCOS resistant to clomifene, what was found to have lower live birth rates compared to laparoscopic ovarian drilling?
Signup and view all the answers
Metformin is advised for insulin-lowering effects as the sole indication for treating hirsutism.
Metformin is advised for insulin-lowering effects as the sole indication for treating hirsutism.
Signup and view all the answers
To avoid gastrointestinal adverse effects, metformin should be taken with ______ and the dose titrated slowly over 4-6 weeks.
To avoid gastrointestinal adverse effects, metformin should be taken with ______ and the dose titrated slowly over 4-6 weeks.
Signup and view all the answers
Match the treatment approaches with the conditions they are used for:
Match the treatment approaches with the conditions they are used for:
Signup and view all the answers
What is the first-line and safest measure to restore ovulation in overweight or obese women with PCOS?
What is the first-line and safest measure to restore ovulation in overweight or obese women with PCOS?
Signup and view all the answers
What is the recommended initial dose of letrozole for infertility treatment in women with PCOS?
What is the recommended initial dose of letrozole for infertility treatment in women with PCOS?
Signup and view all the answers
If weight loss is unsuccessful in restoring ovulation in women with PCOS, ________________ is recommended.
If weight loss is unsuccessful in restoring ovulation in women with PCOS, ________________ is recommended.
Signup and view all the answers
According to guidelines, what should be the first-line fertility treatment for normal-weight women with PCOS?
According to guidelines, what should be the first-line fertility treatment for normal-weight women with PCOS?
Signup and view all the answers
Letrozole is recommended as the first-line option for medical treatment of infertility in women with PCOS.
Letrozole is recommended as the first-line option for medical treatment of infertility in women with PCOS.
Signup and view all the answers
Study Notes
Overview
- Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age.
- It is a leading cause of infertility and pregnancy complications.
- Associated with insulin resistance, metabolic syndrome, metabolic dysfunction-associated steatotic liver disease, and increased risk of developing type 2 diabetes.
Theory
- Epidemiology: PCOS affects about 6% of women of reproductive age in the US and Europe using the 1990 National Institutes of Health criteria.
- Prevalence rates vary depending on the criteria used, with rates ranging from 10% to 20% of women.
- No prospective studies have documented incidence rates for PCOS.
- PCOS accounts for 80% to 90% of cases of hyper-androgenism in women.
- Aetiology: The exact cause of PCOS is unknown, but it is likely to be a complex disorder involving multiple genes.
- Genetic factors: Heritability of PCOS is estimated to be around 70%, suggesting that most PCOS risk depends on genetic factors.
- Susceptibility genes: Several genes have been identified as risk factors for PCOS, including DENND1A, THADA, and LHCGR.
Pathophysiology
- The pathophysiology of PCOS is not well understood, but it is thought to involve interactions between the ovary, adrenal, hypothalamus, pituitary, and insulin-sensitive tissues.
- Insulin resistance leads to compensatory hyperinsulinaemia, which promotes ovarian androgen output and may also promote adrenal androgen output.
- High insulin levels also suppress hepatic production of sex hormone-binding globulin, exacerbating hyper-androgenaemia.
- LH excess is also thought to contribute to ovarian androgen output.
Classification
- There is no formal classification system for PCOS, but a proposed classification system includes:
- Mild PCOS: characterised by irregular periods, polycystic ovaries on ultrasound, mildly elevated androgen concentrations, and normal insulin concentrations.
- Ovulatory PCOS: characterised by normal periods, polycystic ovaries on ultrasound, elevated androgen concentrations, and increased insulin concentrations.
- Hyper-androgenism and chronic anovulation: characterised by irregular periods, normal ovaries on ultrasound, elevated androgen concentrations, and increased insulin concentrations.
- Severe PCOS: characterised by irregular periods, polycystic ovaries on ultrasound, elevated androgen concentrations, and increased insulin concentrations.
Diagnosis
- Approach: Diagnosis of PCOS is largely a diagnosis of exclusion, and there are no pathognomonic features.
- History: Common features include hirsutism, acne, and scalp hair loss, as well as irregular and infrequent periods.
- Investigations: The diagnosis of PCOS can be made when infrequent/reduced menstrual bleeding also exists, and polycystic ovarian morphology is documented on ultrasound.
- Ultrasound: Polycystic ovaries are present in 75% of women with PCOS, but are also seen in up to 25% of normal women and women with other endocrinopathies.
- Serum anti-Mullerian hormone (AMH) levels: May be used as a diagnostic tool, but optimal cut-off values have not been defined.### Diagnosis of Polycystic Ovary Syndrome (PCOS)
Key Diagnostic Factors
- Presence of risk factors:
- Family history of PCOS
- Premature adrenarche
- Female of reproductive age
- Symptoms:
- Irregular menstruation (75% of women with PCOS)
- Infertility (common)
- Hirsutism (60% of women with PCOS)
- Acne (15% to 25% of women with PCOS)
- Overweight or obesity (30% to 80% of women with PCOS)
- Hypertension (common)
- Scalp hair loss (uncommon)
- Oily skin or excessive sweating (uncommon)
- Acanthosis nigricans (uncommon)
Investigations
- 1st test to order:
- Serum 17-hydroxyprogesterone (to exclude 21-hydroxylase-deficient non-classic adrenal hyperplasia)
- Serum prolactin (to exclude hyperprolactinaemia)
- Serum thyroid-stimulating hormone (to exclude thyroid dysfunction)
- Oral glucose tolerance test (to evaluate metabolic risk factors)
Laboratory Tests
- Biochemical hyper-androgenism:
- Calculated free testosterone, free androgen index, calculated bioavailable testosterone, or high-quality testosterone assays (e.g. liquid chromatography tandem mass spectrometry)
- Dehydroepiandrosterone sulfate (DHEAS) levels may be checked if other androgens are normal
- Insulin resistance:
- Fasting insulin levels >69 to 104 pmol/L (10-15 micro-units/mL) may suggest insulin resistance
- Peak insulin levels during oral glucose tolerance test:
- 695-1042 pmol/L (100-150 micro-units/mL) may indicate mild insulin resistance
- 1042-2084 pmol/L (150-300 micro-units/mL) may indicate moderate insulin resistance
- >2084 pmol/L (300 micro-units/mL) may indicate severe insulin resistance
Ultrasound
- Polycystic ovarian morphology allows a diagnosis of PCOS to be made (Rotterdam criteria only)
Additional Tests
- Androstenedione measurement may increase the number of women identified as hyper-androgenaemic by 10%
- Checking DHEAS is of little value except in cases of rapid virilization
Metabolic Risk Factors
-
Prevalence of abnormal glucose tolerance (impaired fasting glucose, impaired glucose tolerance, or diabetes) is as high as 40% in PCOS
-
Odds of prevalent impaired glucose tolerance was 3.3, and of prevalent diabetes 2.9, in PCOS### Diagnosis of Diabetes
-
Diabetes is defined as a fasting glucose level of ≥7 mmol/L (≥126 mg/dL) or a 2-hour glucose level of ≥11 mmol/L (≥200 mg/dL).
-
All women should be screened for impaired glucose tolerance with an oral glucose tolerance test.
-
Those with normal glucose tolerance should be re-screened at least every 2 years.
-
Those with impaired glucose tolerance should be screened annually for type 2 diabetes.
Diagnosis of Polycystic Ovary Syndrome (PCOS)
- Dyslipidaemia is often observed in PCOS, and assessment of fasting lipids has been advocated for all women with PCOS.
- Other tests to consider for diagnosing PCOS include:
- Serum total and free testosterone (elevated levels suggest hyper-androgenaemia)
- Serum dehydroepiandrosterone sulfate (DHEAS) (elevated levels suggest hyper-androgenaemia)
- Serum androstenedione (elevated levels suggest hyper-androgenaemia)
- Pelvic ultrasound (presence of ≥20 follicles in each ovary measuring 2-9 mm in diameter and/or increased ovarian volume)
- Serum anti-Mullerian hormone (elevated levels may indicate PCOS)
- Basal body temperature monitoring may indicate ovulation or anovulation.
- Luteal phase progesterone measurement may indicate ovulation or anovulation.
Differentials for PCOS
- 21-hydroxylase deficiency (partial deficiency of the 21-hydroxylase enzyme within the cortisol biosynthetic precursors) may present with similar symptoms to PCOS.
- Other differentials to consider include congenital adrenal hyperplasia and non-classic congenital adrenal hyperplasia.
Management of PCOS
- Treatment for PCOS may involve adding metformin to clomifene to improve ovulation rates.
- Injectable treatments such as gonadotrophins may be used if other measures fail.
- Gonadotrophins directly act on the ovary, stimulating follicular recruitment and maturation.
- Risks of treatment with gonadotrophins include multiple pregnancies and ovarian hyperstimulation syndrome (OHSS).
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge of Polycystic Ovary Syndrome (PCOS), including its definition, epidemiology, aetiology, and pathophysiology. This quiz is designed for healthcare professionals and students.
