PCOS

PCOS (Polycystic Ovary Syndrome) is one of the most common endocrine conditions in women that emerges at puberty. The clinical features include a triad of hyperandrogenism (oligomenorrhoea, hirsutism, acne), ovulation disorders, and a polycystic ovarian morphology.

Presentation

• Hyperandogenism - Oligomenorrhoea, Hirsutism, Acne

• Insulin resistance - Obesity, OSA, Acanthosis nigricans

• Infertility

• Mood swings, depression, anxiety

• Male pattern baldness

N.B. The pancreas has to produce more insulin, which promotes androgen release but prevents follicular development, therefore leading to anovulation and multiple partially-developed follicles → Polycystic ovaries.

Differentials - Hypothyroidism, Premature ovarian failure, Cushing’s syndrome

These patients are at an increased risk of Endometrial cancer, which is related to the oligomenorrhea. Therefore, this risk can be reduced by ensuring regular periods.

Investigations

The main investigations to do are:

• LH:FSH ratio - Will be raised 2x

• Testosterone - Will be raised

• Fasting glucose and OGTT - For insulin resistance

• TVUS - For ovarian cysts

N.B. Raised LH:FSH also helps exclude menopause, in which the ratio would’ve be normal.

Rotterdam diagnostic criteria - PCOS can be diagnosed if 2 of the following are present:

• 12+ cysts seen in one ovary/ovarian volume > 10 cm3

• Oligo/anovulation

• Clinical/biochemical features of hyperandrogenism (oligomenorrhoea, hirsutism, acne)

Management

• Weight loss! - Vital part of management as it can:

  • Restore ovulation

  • Make periods more regular

  • Improve fertility

  • Improve hisurtism and acne

• Clomifene

• Letrozole

• COCP - if not desiring fertility

• Ovarian drilling (damage hormone producing cells of ovary)

• Topical Eflornithine - for hirsutism