Pcos

Front 1

PCOS differential diagnosis (10 items)

Back 1

Androgen secreting tumor, Exogenous androgens, cushing syndrome, nonclassical congenital adrenal hyperplasia, acromegaly, genetic defects in insulin action, primary hypothalamic amenorrhea, primary ovarian failure, thyroid disease, prolactin disorders

Front 2

PCOS: diagnostic criteria

Back 2

no universally accpeted definition, 3 different diagnostic criteria used (NIH 1990, Rotterdam 2003, androgen excess socitey 2006) all with variations of hyperandrogenism (on physical exam or lab value), oligo/amenorrhea, PCO on US

Front 3

How common is obesity in PCOS?

Back 3

80% will be obese

Front 4

What is the suggested evaluation for patients on physical exam? (4 items)

Back 4

physical: BP, BMI, waist circumference (>35 inches=abnormal), stigmata of hyperandrogenism (Acanthosis nigricans, alopecia, acne, hirsutism)

Front 5

What is the suggested evaluation for patients on laborotory values?

Back 5

total testosterone and SHBG OR bioavailable and free testerone, TSH, Prolactin, 17-hydroxyprogesterone (nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency: random normal <4ng /ml; fasting AM <2ng/ml), screening for other d/o if clinically indicated (Cushings, acromegaly) including glucose tolerance and lipids

Front 6

How is a 2 hour glucose tolerance test conducted and what are the values with each glucose tested?

Back 6

check fasting glucose (&lt;110mg />125=type 2DM), 75g oral glucose load the check 2 hour glucose (&lt;140mg />199=type2 DM)

Front 7

What radiologic studies are considered in PCOS?

Back 7

US 1 or both ovaries: ovarian volume>10cubic cm, >/= 12 follicles measuring 2-9mm. If a follicle in >10mm, re-evaluate later. Check uterus also.

Front 8

Optional lab tests in PCOS (3)

Back 8

gonadotropin levels, fasting insulin in younger women (not routinely recommended), 24h urinary free cortisol excretion or low dose dexamethasone supression (cushing's)

Front 9

Define the metabolic syndrome (Grundy et al. Circulation, 2005). (5 elements)

Back 9

BP>/= 135/85, increased waist circumference (>/=35inches), elevated fasting Glc, reduced HDL (</=50mg/dl), elevated TG level (>/=150 mg/dl)

Front 10

Who should be screened for noncalssical congenital adrenal hyperplasia and how should screening be performed?

Back 10

anovulation + hirsuitism AND high prevalence group: AK Jews, Hispaincs, Yugoslavs, Inuits, Italians. Check fasting 17-hydroxyprogesterone level. If elevated, get ACTH stimulation test-get thee to an endocrinologist!

Front 11

In obese women with PCOS, does weight loss improve ovarian function?

Back 11

yes

Front 12

Does PCOS increase the risk of developing type 2 DM, and who should be screened?

Back 12

2-5x increased risk of DM with PCOS. All women with PCOS should be screened with 2hr glucose tolerance test.

Front 13

Does PCOS have a long-term effect on the development of cardiovasuclar disease and who should be screened?

Back 13

All women with PCOS should be screened: BMI, fasting lipid and lipoprotein levels (high lipids in ~70%PCOS), and metabolic syndrome risk factors.

Front 14

In PCOS woman not trying to conceive, what is best medical maintence therapy to treat menstrual disorders?

Back 14

Combination low-dose OCP (decreases LH, decreases ovarian androgen production, increases SHBG), progesterone only not as good/studied, Biguanide (metformin) or Thiazolidinedione (rosiglitazone)

Front 15

In PCOS woman not trying to conceive, what is best medical treatment to reduce risks of CV disease and DM?

Back 15

lifestyle modification, insulin sinsitizing agents (metformin), statins, possibly combined low-dose OCP

Front 16

In PCOS woman trying to conceive, which methods of ovulation induction are effective?

Back 16

First line: Clomiphene citrate. Dexamethasone as adjunct may increase ovulation rates. Second line: low-dose gonadotropins, ovarian drilling (not well studied); 1st vs 2nd line-Aromatase inibitors (letrozole and anastrazole), insulin sensitizing agents (metformin preferred since category B)

Front 17

What medical methods are used to treat hirsuitism in PCOS? (4 general categories)

Back 17

No clear primary medical treatment. OCP + antiandrogen spironolactone (dose=25-100 mg BID- watch for hypokalemia and orthostatic hypotentionmay help. Other antiestrogens that are more teratogenic = flutamide and finasteride. Insulin sensitization agents have little or no clear benefit. Eflornithine topical FDA approved for femal facial hirsutism is successful 60% decrease in 6 months with 1/3 clinical success. Laser good.

Front 18

Level A recommendations: 4

Back 18

lifestyle changes are as good as or better than medication; improving insulin sensitivity decreases circulating androgen levels, improves ovulation rate, and improves glucose tolerance; first line treatment for ovulation induction is clomiphene citrate; addition of eflornithine to laser is superior to laser alone.

Front 19

level B recommendations: 5

Back 19

Screen for Type 2 DM with 2 hr GTT; screen for cardiovascular risk with BMI, fasting lipid/lipoprotein levels, metabolic syndrome risk factors; recudtion in weight if obese = improved pregnancy rates, decreaed hirsutism, improved lipids and glucose tolerance; incrased pregnancy rate buy adding clomiphene + metformin esp. in obesity; second-line for ovulation induction = exogenous gonadotropin or ovarian surgery

Front 20

Level C recommendations: 4

Back 20

Combination low dose OCP are recommended as primary treatment for menstrual disorders; if high risk group, screen for nonclassical congenital adrenal hyperplasia with 17-hyproxyprogesterone; low dose gonadotropin recommended due to increased risk of hyperstimulation and multifetal pregnancy; no clear primary treatment for hirsuitism in PCOS.