Polycystic Ovarian Syndrome (PCOS)

Last updated 25.08.13

 

Index

 

 

Definition

-  Chronic idiopathic endocrine disorder associated with increased androgens &/or hyperinsulinaemia

 

Features

-  Diagnosis of exclulsion

-  Disorder of androgen & oestrogen metabolism

-  12-21% of reproductive age women in Australia

-  70% unDx

-  Increased incidence in obesity & indigenous

-  Major cause of infertility

-  Obesity increases S/S

 

Dx

-  Rotterham Criteria

-  2+ of

-  Oligo or anovulation

-  Clinical &/or biochemical hyperandrogenism

-  Polycystic ovaries on US

-  PLUS exclusion of

-  Hypothyroidism

-  Hypoprolactinaemia

-  Congenital adrenal hyperplasia

-  Androgen secreting tumours

-  Cushings syndrome

 

Associated S/S

-  Hyperandrogenism 60-80%

-  More common in adolescence

-  Hirsuitism

-  Acne

-  Male pattern hair loss

-  Deepening voice

-  Clitoromegaly

-  Menstrual problems

-  More common in 20s & 30s

-  Secondary amenorrhoea, oligomenorrhoea

-  Irregular cycle (<21 or >35 days)

-  If 2yrs post menarche consider PCOS

-  Dysfuctional Uterine Bleeding (DUB)

-  Infertility (NOT all pts)

-  Increased in pts >35yrs & BMI >31

-  Metabolic

-  More common >30yrs old

-  Hyperlipidaemia

-  HTN

-  Obesity >50% (BMI)

-  OSA (increased incidence independent of BMI)

-  Insullin resistance 50-80%

-  Prediabetes

-  10% have DM2

-  Relatives at increased risk of DM2

-  Psychosocial

-  Anxiety

-  Depression

-  Psychosexual dysfunction

-  Eating disorder

 

DDx

-  Pregnancy as a cause of amneorrhoea

-  As per Rotterdam Criteria

-  Hypothyroidism: TFT

-  Hypoprolactinaemia: serum prolactin

-  Congenital adrenal hyperplasia

-  Androgen secreting tumours

-  Cushings syndrome: S/S

 

Ix

-  Beta hCG: exclude pregnancy

-  Androgens

-  Typically require 3 months free from OCP

-  For hormone levels to be accurate

-  Requires alternative contraceptive cover

-  Serum 17-hydroxyprogesterone in follicular phase: exclude 21-hydroxylase def (congenital adrenal hyperplasia)

-  Calculated Bioavailable & Free Testosterone: elevated

-  OR Free Androgen Index

-  2nd line

-  Androstenedione

-  Dehydroepiandrosterone sulfate

-  TV Ultrasound

-  12+ small follicles in each ovary

-  Enlarged ovary (>10ml)

-  Uni or bilateral

-  String of pearls

-  FSH

-  If irregular cycle can determine where in cycle

-  +/- Oestradiol + PG: establish where in cycle

-  TFT: exclude hypothyroidism 

-  Prolactin: exclude hypoprolactinaemia

-  K10: depression

-  Cardiovascular Risk Assessment

-  Family Hx

-  Ethnicity

-  Smoking Hx

-  BP

-  Lipids

-  OGTT: prediabetes or DM2

-  2nd yearly OR annulay if increased risk

-  Waist circumference: >80cm increased risk

 

Mx

-  Lifestyle interventions

-  Smoking cessation

-  Nutrition

-  Exercise >150 min/week

-  Weight loss 5-10% improves IR & S/S

-  Allied health

-  Psychologist

-  Dietician

-  +/- Exercise physiologist

-  Specialist referral

-  Endocrinologist

-  Gynaecologist

-  Dermatologist

-  Mx DM2 & Metabolic syndrome

-  Infertility

-  Lifestyle 1st line for 3-6 months

-  THEN Clomid (Clomephine)

-  Weight loss 1st if BMI >35

-  THEN Add Metformin if poor response

-  Gonadotropins 3rd line

-  Surgery

-  Laparscopic ovarian drilling

-  Bariatric syrgery

-  ART/IVF

-  Oligomenorrhoea

-  Consider progestogens each 3-4 months to induce withdrawal bleed to prevent endometrial hyperplasia

-  Hirsuitism

-  Cosmetic therapy 1st line (electrolysis, wax, shave, laser)

-  +/- Eflornithine cream

-  +/- Oral Contraceptive Pill

-  +/- Spironolactone 50-100mg BD

-  Teratogenic so must use contraception

-  Antilipid drugs not routinely recommended

-  Pregnancy

-  Screen for GDM prior to 20/40

-  Cease Metformin

-  Increased risk of complications

-  Anovulation

-  Laparascopic ovarian electrocautery in pts w normal BMI

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References

 

MJA: Assessment & Management of PCOS: EBM Guideline 19/09/2011

RCOG Greentop No. 33: Long Term Consequences of PCOS