Pcos

Front 1

• Clinical features

Back 1

Front 2

• Definition

Back 2

The presence of two of three:
• Clinical and/or biochemical signs of hyperandrogenism
• Oligo and/or anovulation
• The appearances on ultrasound of “polycystic ovaries”
Exclusion of other known causes

Front 3

Ultrasound appearances

Back 3

Front 4

- Definition/Dx

Back 4

The Polycystic ovary should have at
least one of the following:
• 12 or more follicles measuring
2-9mm in diameter
• Increased ovarian volume
(>10cm2)
If there is a dominant follicle or corpus luteum, the scan should be repeated.

Front 5

• Pathophysiology

Back 5

1. May have excess primordial follicles in PCOS
2. INTERCYCLE FSH RISE: cruical for one egg to be selected
- transiently rised only long enough for one follicle to mature (IVF: high FSH, thus can stimulate 10-12 follicles to stimulate)
- Women on the pill are on it to avoid this FSH rise (but everything else is normal)
3. LH surge is an automatic step that follows FSH rise (thus the FSH rise is most important)

IN PCOS: they dont have the FSH rish thus no dominant follicle forms

Front 6

Steriod Synthesis

Back 6

Front 7

Ovarian follicle
development 1

Back 7

Front 8

Steriod Synthesis in follicle

Back 8

the FSH selects the follicle

Front 9

The follicle in PCOS

Back 9

thus excess testosterone

Front 10

The normal menstrual
cycle

Back 10

Front 11

Pathophysiology of PCOS

Back 11

Front 12

Pathophysiology of PCOS: LH and FSH levels

Back 12

Front 13

Pathophysiology of PCOS: Sx Mechanism

Back 13

Front 14

Why is the LH concentration increased?

Back 14

Physiology
Prolonged exposure to unopposed estradiol increased GnRH pulse frequency
?? Antenatal programming?

Front 15

Physiology of the normal hypothalamo-pituitary axis
GnRH..

Back 15

LH mainly driven from above

FSH mainly driven from below

GnRH pulsatility is required for effective pituitary function
- they speed up in the first half of the cycle

- then slows down for PG phase of cycle

Front 16

Physiology of the PCOS
hypothalamo-pituitary axis

Back 16

Estrogen: drive the pulsatility (SPEED)
Progesterones: slow it done and because in the PCOS there is no PGs the Es effect keeps getting faster and faster

insulin makes the thecel cells grow and make more testosterone (thus makes the problem)
thats why women overweight they develop PCOS

Front 17

Why is the insulin concentration increased?

Back 17

• Obesity
• Insulin resistance
• ?? Androgen effect in utero

Front 18

• Investigation

Back 18

• Ultrasound scan: important to collaborate
• LH, FSH, PRL
• Gestogen withdrawal bleed if amenorrheic
• Ovulation check if menstruating
• Testosterone
• Oral glucose tolerance test with fasting insulin If clinically hyperandrogenic
• DHEAS
• 17OH progesterone

Front 19

PRL

Back 19

need to exclude amenorrhea due to prolatinoma

Front 20

Anti-mulleriane Hormone

Back 20

anti-maliraina hormone

- previously guess the amount of egges a women had
- this hormone estimates how many eggs the women has
- high MAH levels DDx amenorrhea from PCOS

Front 21

Gestogen withdrawal bleed

Back 21

because they dont have normal periods (no PG levels normally)

Front 22

Testosterone

Back 22

important to check testosterone level (only slightly increased in PCOS) other conditions >5 more serious condition (adrenal gland problems or tumours)

Front 23

DHEAS

Back 23

one androgen exclusively from adrenal gland
- exclude congenital adrenal hyperplasia

Front 24

Treatment

Back 24

- Clinical Features of PCOS, there is no cure, but then you need to ask the patient what she wants to achieve and what Sx to concentrate on
- However you do need to treat, to red. the risk of endometrial cancer

Front 25

Hirsutism

Back 25

Anti-androgen or 5 alphareductase inhibitor
- blocks the conversion of 5DHT to Testosterone

- BUT CANT use them, because it will affect gender selection in pregnagnyc (we are all destined to become females until the testosterone comes along and with a series of long and sophicitated steps, turns us into the sophisticated males that we are

- thus never allowed to use this in young women (by drug companies- to protect themselves)

Front 26

Irregular/ heavy bleeding

Back 26

Progestogens or the contraceptive pill

Front 27

Anovulation

Back 27

Anti-estrogens or aromatase inhibitor

Front 28

Ovulation induction:

Back 28

Clomiphene citrate
• Use Days 2-6
• Careful instruction and tight monitoring the key to success
• Generally not more than 6 months

Front 29

Clomifene citrate: the problems

Back 29

• Side-effects include hot flushes and headaches
• Induces ovulation in 70% but pregnancy in only 30-40%
• Adverse effects on endometrium and mucus
• Aromatase inhibitors promising but no large randomised controlled trial available for comparison (to block estradiol synthesis)

Front 30

Effects of Metformin

Back 30

not as clear cut
-HOWEVER they do have SE.
Side effects;
not pleasant stuff to take so need a good reason for taking it

• Effective in ovulation induction
• May be helpful in IVF
• Side-effects can be problematic
• NO data on long-term benefits or risks in women with PCOS

Front 31

Management of anovulation at Westmead Hospital

Back 31

Front 32

Low dose gonadotrophin treatment

Back 32

1. Give gestogen to induce withdrawal bleed.
- period 7-10 days later
2. Give slowly increasing doses of gonadotrophin until oestradiol > 400pmol/L. Injections given daily
3. Daily oestradiol measurements and alternate
day scans until one (two max.) follicle(s) seen greater than 17mm diameter
4. Give hCG 5000 IU to induce ovulation

Front 33

Ultrasound appearances

Back 33

laser holes into the ovaries that seems to work (but we dont know how it works)