Polycystic Ovarian Syndrome


Epidemiology


5-7% of population

Aetiology


Genetics?? --> Follicles in ovaries; LH increases
Insulin resistance ie increased risk for DM, heart problems
Androgens in ovaries- causing hirsuitism, acne, alopecia, ie follicle atresia

Signs and Symptoms


Andronization e.g. acne, hirsuitism (use spironolactone)
amenorrhoea/oligomennorhoea/dysmenorrhea
obesity (use metformin)

decreased SHBG- sex hormone binding hormones
fHx- GTT, male baldness?

Diagnosis



AES criteria 2005:
Anovulation and/or oligorrmenorrhoea +/- U/S finding of 46mm > 12 follicles
Hperandrogenization

(U/S findigns may be evident in 1/4 women; may be normal)

Investigation



FBE (on day 2/3 of period)- LH, FSH, prolactin, TSH
U/S
OGTT

Treatment




Oral Contraceptive Pill
anti-testosterone "Diane" ciproterone acetate
Provera 20 days (no E2; absent withdrawal bleeding)
role is to decrease ovarian dysfunction

Metformin
2nd line: may add metformin
metformin (category C drug ie not to be used in pregnancy; unknown mechanisms helps with ovulation - maybe insulin resistance?)
S/E: NV (lose weight), diarrhoea; lactic acidosis (in DM pop.)

Surgical punctuation of follicles- short term measure

Clomid
for ovulating
1st line: Clomid (Estrogen binders to increase FSH and E2)
1 tablet/day day 5-9 of period
Day 21- E2-P4 test to test for ovulation
double dose later months if suff. (max 3 tablets work up from lower doses)
use for 3-4 months; if 6 months no pregnancy-> Ix)

S/E of Clomid
hot flushes
stimulate >1egg release (ie twins)

Complications



"M-OHA- GE"

Short term
  • Menstrual changes and fertility
  • Virilism x 3: Hair, Obesity, Acne
Long term:
  • Gestational Diabetes. Metormin prevention
  • Endometrial hyperplasia. IUD/Prog injection

Differential Diagnosis



Premature menopause
PCOS (LH: FSH = 2:1)
hypothyroid
hyper-prolactinaemia

Rx:
carbapoline
bromoepine



Infertility

Age is the ultimate determining factor for infertility

Aetiology


30% Pr of pregnancy/cycle
ie 90% after 3 months
chances decline at 30y.o
ie IVF earlier maternal age preferred

There are three most common anovulation states:
  • PCOS (increased LH)
  • Menopause (increased FSH ie >10U)
  • Anorexia (decreased FSH, decreased LH, decreased E2; resulting from decreased negative feedback loop from lowered oestrogen levels)

Anti-Mullerian hormones AMH is produced by male fetuses to suppress ovarian synthesis.
AMH is also used as an indicator for ovarian reserve. It consists of a blood test; since AMH does NOT fluctuate with cycle, advise of egg reserve and possibility of premature menopause.

Epidemiology


20-25 years of fertility from menarche.

Investigations


How old is the woman?
Is the woman ovulating? temp, beta HCG, progesterone, LH FSH, TSH;
Take sexual history!

  • Blood
Day 21 progesterone (test for subfertility)
[+] temp rise of 0.5 degrees celsius due to D21 progesterone)

  • Histo-salpingogram (using dye)
test for tubal patency

  • Male spermatoanalysis

Management


  • Address cause (anti-oestrogen clomiphene and weight loss in PCOS, increased weight gain and psych factors in anorexia). ie WEIGHT
  • Clomephene oral day5-9 which decreases E2 to increase FSH release (does not work for anorexia);
S/E: hot flushes, mood :(, 10 percent pregnancies from clomid = twin pregnancies; 150mg max dose
then U/S to review follicle; betaHCG levels- ovulates 36hrs later
Day 24 progesterone; do body temp chart (thermometer at bedside table)
  • FSH injection (for anorexia) for direct ovulation induction; ovulates 36hrs later- advise lots of sex!
  • for prolactinoma: CT scan of head; micro (less than 1 cm) use dopamine-antanoists; for macro (more than 1cm), neurosurgery; may cause space-occupying lesions
  • IVF