varied and often complex array of metabolic and endocrine abnormalities

can lead to long term health issues

Background

• prevalence 5-10%

• most common endocrine disorder amoung young women

• PCOS often undiagnosed

Aeitiology

• Cause not fully understood

  • polygenic componenet

• insulin resistance = important element in development

Long term health risks

• increased risk

  • impaired glucose tolerance

  • metabolic syndrome

  • gestational diabetes

  • Type 2 diabetes

  • HTN

  • dyslipidaemia

  • CVS disease

  • Fertility issues

  • endometrial hyperplasia

    • endometrial cancer

    • (unopposed oestrogen)

• increased risk of OSA, irrespective of BMI

• association between breast and ovarian ca - evidence conflicting

Diagnosis

Rotterdam

2 out of 3 of:

• Oligo or anovulation (60-70%)

• CLinical and/or biochemical signs of hyperandrogenism (70%)

  • hirsuitsm

  • acne

  • male pattern baldness

  • elevated total/free testosterone

• polycystic ovaries

  • ≥ 12 follicles of 2-9mm diameter and / or increased ovarian volume (>10mL)

35-50% obese

22-33% have polycystic ovaries on USS

Aanthosis nigricans (1-3%)

history

• reproductive health

  • menarche

  • past and present cycle

  • oligo/amenorrhoea

  • menorrhagia

  • miscarriage

  • infertility

• presence of androgenic symptoms

  • ance

  • hirsutism

  • alopecia

• Lifestyle

  • bodyweight

  • eating and exercise

  • etoh

  • smoking

• family history

  • PCOS

  • DM

  • hirsutism

  • premature male baldness

Exam

• Weight

• acne and hirsutism

• blood pressure

• abdominal striae

  • weight change or Cushing’s syndrome

• bimanual

  • ovarian enlargement

    • pelvic exam poor predictor of polycystic ovaries

    • especially if BMI high

• Virilisation may raise concerns about other serious conditions

Investigation

• exclude pregnancy

• Pelvic ultrasound

  • important as part of diagnostic criteria but not a must do if diagnosis made on clincial/biochemical grounds

• free testosterone

  • usually increased

  • more sensitive for identifying physiologically active androgens

  • total testosterone adn Sex hormone binding globulin

  • very high levels of total testosterone:

    • late onset congenital adrenal hyperplasia

    • cushing’s syndrome

    • adrenal/ovarian tumour

  • SHBG level dec. in PCOS

• after diagnosis

  • if fasting >5.5 or random >7,7 then OGTT

    • ?HbA1c

  • Lipids

    • CV risk

  • FH/LSH

    • LH often increased

    • FSH usually normal

      • increase ratio

    • LH predict future complications

• Tests to exclude other conditions:

  • Prolactin

    • (Galactorrhoea, irregular/absent periods)

  • TSH

  • Oestradiol + FSH

    • exclude premature ovarian failure

      • low oestradiol, very high FSH

  • 17-OH progesterone

    • exclude late-onset or non-classical CAH

      • rare

    • difficult to distinguish from PCOS

      • family history

      • less menstrual distruption or history of early growth of pubic hair

  • DHEAS

    • adreanl androgen production

    • high levels = adrenocortical tumour

  • Androstenedione

    • ovarian androgen production

  • 24hr urine cortisol

    • Cushing’s sybndrome

Treatment/management

Lifestyle modification = decrease weight

• even modest weight loss - 5% - will reduce central obesity and insulin resistance

• improve endocrinological abnormal

• menstrual irregularity - including increasing rate of ovulation

• women who succesd in losing weight

  • more likely to achieve and have healthier pregnancy

  • reduce risk of gestational diabetes

• longer term benefits

  • reduction in insulin resistance

• weight loss not required if BMI within normal range

Treatment for acne and hirsutism

• anti-androgens

• topical agents (particularly for acne)

• local hirsutism treatments

  • electrolysis

  • laser

• psychological support

Do not test insulin

• poor measure of insulin resistance

First line anti-androgenic therapy

• combined oral contraceptive

  • containing cyproterone acetate

  • +/- spironolactone

    • 100-200mg/day

  • higher doses of cyproterone or spironolactone may be combined with COC

Regulation of menstrual cycle

• weight loss

• COC

• progesterone therapy

  • if coc not tolerated

• use these hormonal treatmetns to protect endometrium from unopposed oestrogen stimulation in women who have chronic anovulation

Metformin

• insulin sensitising agent

• decrease insulin levles

• therefore reduce androgen production

• currently no evidence to support

• (( 1g bd in women with BMI \<25 )) - from seminar???????

Infertility

• if main presenting problem;

  • refer to fertility specialist

• weight reduction